05120028 CITY OFCUPERTINO I h;dSaw
BUILDING DIVISION PERMIT COI�ITRACTORANFORh'IAT
BUILDING ADDRESS: PERMIT N0.0 5512 0 0 2 8
06 3 CHERYL DR
OWNER'S NAME: PERMITISSUEDATB
JANE WADLOW 12/06/2005
ONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
306 LICENSED CONTRACTORS DECLARATION JobDescri tion
�e G+F I hereby aRUm Net 1 am licensed under provisions of Cha mer 9(commencing P
-C with Section 7000)otDivislan S of We Business aha professions Code,and my license is
z a full force
and Z a tie.« �/�l �1Y REPLACE FURNACE
Dme"�'C Cmummoor CONTRACTOR: MTL CONTROLLED SYSTEMS
3 ARCHf1ECi'S DCCLARATIO
9 01u I undomm nd my plana shall he used as public Reside
g ud� Licensed Pmfessianil
3 OWNER,BUILDER DECLARATION
I I hereby affirm that I am exempt from the Conlnctah License Law for thp
W0 O fallowing mason.(Sma et 703 1.5,Business and Profewons Code:Any city or county
S$ which acquires a Permit to eovWR,alar.Improve,demolWt,or repair any structure
iy poor to its issuance.also mquims the applicant for such permit to file ulgned mooren
FFF< On[heI,Eannd pumuanl mdse provisions of the contm[Wr•s Ummo Law(Chapter Sq.Ft.Floor Area Valuation
3$ (commencing with Scalae 7000)of Division 3 of the Business and Profeuimu Code)or
3 Nat he is exempt therefrom and the bash for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit objects the applicant W a civil penalty of APN Number Occupancy
Am mac than five hundred dalWa(M). P y Type
❑1,as owner of the property,or my employees with mgus not their ole compensation,
will domaweak..adthe structure is not intended aalferedfaaale(Sm.70",Business Raired
and PrefesslOv Cat:The Conusctofs Llance law dean not apply W e an Owner of q
propenywho buildn orimprows sheron,andwha daasahwork himself orthrough his
awn employees.provided that tach improvements are not intended aortered for sale If. A
however,the Wilding u Improvement ts n bed i in of buil r of completion purpose
ower- ryN
builder will have Oat burden of proving out he did not bold of Improve for purpose of '{r
ale.). 6
❑1,as Owner of the property am exclusively contracting wish licensed contractors to
construct the Project(Sec.7014,Business and Professions CWe)The Contaaubrt U. Os
cave law does oat apply W an Amer of properly ween builds or Improves;Merton.and,
who mmusicu fa such projects with a c,mmema(U licensed pursuant W the Contractors
Llmone Law.
❑I am exempt under See .B&P C fa this mann
130710
ner Data
WORKER'S COMPENSA71ON DECLARATION
I hereby aOLm under penalty of perjury ansa of the following declarations:
I have aha will maintain aceAOab,of content W albWs me fa workers compen.
lon,u provided for by Section 3700 of the labor Cmc,fa the performance of she
rk for which this permit Is leaned.
1 have and will maintain Wafers Compensation Insurance,ax required by Section
ofthe Labor Cade,for due performance ofthe wart far which this permit is issued.
Workers Compensation mane artier nd Policy number are:
Merl�xlnvdme� Policy No.: A1Qf12Z67
CERTIF ATEOFEKEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(This Auction need Out be completed Iflhe lemic in forane hundred donors($100)
alas.)
I tial that In the performance of she wart for which this Permit is issued.I shall not
employ any person in any manner an As W become object to the Workers'Compensation
Laws of c irmal..Data
Applicant
NOTICE TO APPLICANT.IL after making this Cenillcaue of Exemption,you should
become object W she Worfa's Compensation provisions of the labor Code,you most
.J Z forthwith comply with steh proviaov or thin permit shall W domed revoked.
3► CONSTRUCTION LENDING AGENCY
(—t (hereby MD.out then iso constsadrm Lending agency lathe incrormmaof
ori�: the anal,fa which this permit is issued(Sec.3097,Civ.C.)
4 Lender,Name
7 z IandeesAddnues
U Q I certify that I haw mad this application and Audi that Ne&hove Information Is
D,F correct.1 agree W comply with all city and county oolinancaa and sub,ism retailing W
Q building convection.and hereby authorise repreunutivel of this City W enter upon de
C above-mentioned properly for inspection purpOWL
(We)agree tu tow,Indemnify and keep harmless tits City of Cupertino against
.:H llabilioo,judgmcnla,eau and expetua which may in any my attoc galvt said City
in
Of the grunting of
()n'<
APPLICANT OUNDERSTANDS AIND WILL COMPLY WITH A NONPOIM Issued by: Date
SOURCE REGULATI S. _
Re-roofs
Signature of ApplicAm Canir r Dau
HAZAR US MATERIALS DISCLOSURE Type of Roof
Will the applicant or fu�re building aeupant sum,or handle hoomous material
As claimed by she Cupertino Municipal Code,Chapter 9.12.and On Health and Safety
cede,peva 25532(')7 /,j�$/Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant on equipment or devicas which If a roof is installed without first obtaining an inspection,I agree to remove
It hwardaus air formation u defined by sho Bay Area Air Quality Management all new materials for inspection.
Nicfl
❑Yc& PC
I hew read de hvardau mamtliltmyuiremenu underChapmrg.95 oltiu Glifor.
nia Health&SafetyCOde.Socdau25505,25533 a a 125534.1 understand lhatif he Wilding
does not currently hew a meant.that It is my responsibility W artily tim oaupanl of the
reyulremcnu which Wme poorWissuana afa CcrdOcemafOc[upy�' Signature of Applicant Date
(z 6 s All roof coverings to be Class"B"or better
Owner err othoamd ages am
a Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
�UPERTINO
Building,Deartment
JOB ADDRESS: PERMIT#
OWNER'S NAME: / a,f PHONE # Sb-9cy- &,TS-3
GENERAL CONTRACTOR: gom M-rL, e„ FAX # 65v-- 96*1-9s'z3
gys�.c
I am not using any subcontractors: /a -6/05—
SiEWature Date
Please check applicable subcontractors and com ete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
e /Contractor Signature Date
CITY OF CUPERTINO
aI DFURNACE/AC �( Z
*UPEkTINO PERMIT APPLICATION FORM
APN # 3S� /Sr- o�4 Date:
Building Address:
Owner's Name: p Phone#:
�o,& �oVI/ 4x$ — Z:Ss-- O t oc>
Contractor: 1 r Phone: License#:
MTU Con�ro�`t� S � lnn . GSD-96H-83S3 C-Zo 96f87U
Contact: yy� 11 Phone: Cupertino Business License#:
�KQr �.k. SaM V
Building Permit Info:
Bldg ❑ Elect)s Plumb Mech
Job Description: 1 1(�'
�e 161C.r �"v r^acs— p
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor K 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project- Type of Construction: Occupancy group:
Strapped ❑ �p On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm 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
J MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Pi in S stem Fee PLUMBING
BUSLIC Business License BUILDING
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