03110063 .t CITY OF CUPERTINO ? _ ��"
BUILDING DIVISION PER .O ONTRACiTOR INF,ORMA.TIO,1V'..v
BUILDING ADDRESS: AIR QUALITY HEATING & AIRC YMMIT N003110063
743 CASTLETON ST
OWNER'S NAME: 1233 'PEDRO ST PERMIT ISSUE DATE
SIMON JULIUS S AND MICHELLE 11/12/2003
NE; (408) 293-7138 SANITARY N0, CONTROL NO.
ARCHITECDENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
fo 0 0 0
100 LICENSED CONTRACTOR'S DECLARATION ,
1 hereby affirm that I am licensed under provisions of Chapter 9(commending - Job Description
With Section 7")of Division 3 of the Business and Professions Code,end my license la
infulifomeondcffe REPLACE FURNACE A/C . DUCT & 2 ZONE SYSTEM
Lie.l DamnseC11 LRC Curt Manor a f FINALE®
AR CHIT he TS DECLARATION 4Trf-
I undcr¢mnd my plans shall be recd as public rcrnms
>�G NOV 2 1 2003
a G h Licensed Professional
g g OWNER-BUILDER DECLARATION
20Z I hereby Sarno thin I [. exempt from the Gssionso e:Any
Lew for the
p O following remon.(Section 703[.5,Business and Professions Code:Any city or county
$ which requires a permit re construct,eller,improve,demolish,or repair any statement
IIs
poor was tensed c,.. requires thovisio antsof for such Contractor's
ontra tar's Licenfile ase
ase(Chapter
cm _
Z< Mmarencat he is ingsed pursuant ha the Of Division 3 the eBusinssand Professions
Code)or Sq.Ft.Floor Area anon
g'S tt C (ca he is exempt
Sectionfom y10)of Division)of the Business and Pro(casinns C.dc)or
that he u exempt mcrefrom and do basis far the alleged exemption.Any violation of 35618070 . 00
Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of APN Number , Occupancy Type
not more than fmc hundred delta.(SSW).
[D 1,as...or of the property,or my employees with wages as their sale compensation,
will do the work,and the SWeture is not intended or offered far sale(Sec.7D44,Business
and Professions Coda:The Contractor's License Law dace not apply to an owner of Required Inspections
property who builds or improves thercoo,and who dneasuch work himsclfar through his
own employees,provided that such improvements are not intended or offered for sale.It,
however,the building or improvement is sold within one year of completion,Ne owner.
builder will have me home.of proving mat he did not build or improve for purpose of
sale.). -
❑1,as owner of the property,am exclusively contracting wit licensed contractors to
construct the project(See.7004,Busincu antl Profes¢ions Code:)The Contractors Li-
cense LOW does not apply to an owner o(property who builds or improves Uamon,and
who contracts for such projects with a eonowtor(s)licensed pursuant in to Convectors
License Law.
❑I am exempt under Sec. ,B&P C far thio moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affl m under penalty of perjury one of to following decimations:
1 have and will maintain aCcnifcate,of Consent to self-insure for workers Camper. -
.ation,u provided for by Section 37M of d,e labor Code.for to performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as,required by Section
]00 of me Labor Code,for dm performance of me work far which this permit is issued.
My Workers'CCn/q-.puss ion insure seamier and Policy number am /
Cartitr.jJ[� Policy No.;
CE FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Isforonc hundreGdollars(SIM)
or)ass)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as t become subject to the Workere Compensation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Certifuam of Exam prion,you should
become subject to the Worker's Compensation previsions Of the Labor Crude,you mum
'O forthwith comply with such provisions or this permit shall be deemed invoked.
Z CONSTRUCTION LENDING AGENCY
tCn-t I hereby affirm Net them is a construction lending agency for the performance of
'Sa the work for which this permit is iuucd(Sec.3097,Civ.C.)
{t7 Q Lender's Name
= z Lender's Address s
U 0 I certify that 1 have read this application and state that the above information is
U.F correct,1 agme to comply with all city and county ordinances and auk h vS relating to
DU building construction,and hereby authorise representatives of mis city m enmrupnn the
94 abowe-mentionad
agree
property for Inspection ennifpurposes.
tl, (Wc)agme to cove,indemnify and keep harmless the City of Cupertino against
h inconsequence fthecostsang eapensce which may in anyway eceme against said City
U 7�.. A consequence of UNDERSTANDS
of tis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NO POINT Issued by: Date
SOURC LATII
S�/�Sfir't �� Z e ri Re-roofs
Sgnx of plicaHAZA HAZARDOUS MATERIALS DISCLOSURd Type of Roof
Will the a Cupertino
or future bulling e,Chapter
store or handle Health andSafrmaterial
as defined by the Cupertino Municipal Code.Chapter 9.12,mtl the Health and safety
ode,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye WN.
Will the applicant or future building Occupant use equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
It haxemous air contaminants as dcfincd by the Bay Area Air Quality Management all new materials for inspection.
istrin?
❑Yes Pon
1 have read the heraamous materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code.Sections 35505.25533 and 25534.1 understood that if to boiling
dors not currently hove a tenant,that It is my responsibility m nodl'y lbe omupam of the
m4tdoemcn must be at prior wi¢aounce of a CerdOcaueof cap cy. Signature of Applicant Date
l/ Z All roof coverings to be Class "B" or better
Own m ivcd agcm Dam
CITY OF CUPERTINO 0 3 100
"btm
� FURNACE/AC
CUPEI�TINO PERMIT APPLICATION FORM
APN # :10D Date:
�/ //1/0 3
Building A(idress: C
Owner's N e Phone #:
Klo -Z.39
Ctract Phone: License#:
La-6-y� e- Z-6 7�9YY
Contact: J Phone: Cupertino Business License#:
YL or —z93 -7/3 �
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job escription:
Residential Commercial ❑
For Residential I st Mations:
Attic ❑ 151 floor 2"d floor'EK
Adhere to niin sot back requirement❑
For Commercial Installations:
Replacem s weight ❑ Additional weight (structural calcs) ❑
Struc al Calculatio required for new installation ❑
Ne installation Planni Approval Re uired ❑
C st of Project: Type of Construction: Occupancy group:
Strapp On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacemen
Qty. i
AnDli a e Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
B SLIC Business Licens BUILDING