03070217 .i CITY OF CUPERTINO
BUILDING DIVISION PERMIT 4CONTRACTOR I�NPORMATI,
aulLOINGADDRESS: RESIDENTIAL HEATING AND A/ ERtKND03070217
OWNER'S NAME: 65 CRISTICH LN PERMIT ISSUE DATE
LAW MARK A ANT) T.ATT7.R MARY T. 07/29/9,003
ONE: 4083774073 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0
300 LICENSED CONTRACTOR'S DECLARATION Job Description
e C I Mmby Arm that 1 em licensed under provisions of Chapter 9(commencing - p _
c b with Ito Of0) fDivision Jof M.B i eared Profcuimu Cnde,mdmylummis
in full endo t. d [S NEW FURNACE A/
Liat m.N
W❑ D �xfra U
(q- CHITECT RATION
e$ Iundcminimyplans MallWu¢Xupublicnemet )'
)yU
e C to Licensed Professional oil 5 OWNER-BUILDER DECLARATION
1 hereby affirm that I em exempt from Ne Contractor's License Law for the
p O following recon.(Section 703 1.5,Business and Prof=iuv Chat:Any city or county
5 S 2 which requires a permit to conswel,altar,improve,demolish,or repair any structure
Zot prior hs its issuance,also requires the applicant for such permit to O lc a signed statement
¢ < that he is licensed pursuant to Me provisions or Me Contractor's Limense Law Chant,9 Sq.Ft.Floor Area Valuation
2 O (commencing with Section 7")of Division J of the Business and Professions Code)or
3$ that he h exempt therefrom and the basis for the allcgW exemption.Any violation of 32618018 . 00
Section 1031.5 by airy applicant for a permit subjects Ne applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars($30(l).
❑I,as owner of tits progeny,or my employ=with wages As their tele compen tuan.
will do the work,and Ne alruclum is not intended or offered for sale(Sec.]OCA,Business KUU U171
—
and Proressions Code:The Contractors License Law d=not aPFIy m an owner of 303 - ROUGH MODS
proNnywho builds or improves thereon,and whodneuuch work himself or through his L
own employ=,provided that such improvements are not Intended or offered formic.If. 304 — ROUGH ELECTRICAL
however.the building or improvement is mid within one year of completion.Ne owner
builder will have the burden of proving that he did not build or improve for purpose of 505 - FINAL ELECTRICAL
ale')' 507 - FINAL PLUMBING
01.a owner of the property,am exclusively contracting with licensed centimeters to 508 - FINAL MECHANICAL
constmct the pmjcm(Sec.7041,Business and Professions Code:)The Contractor's Lt.
cove taw d=not apply in an owner of property who builds or improves themon,and
who contracts for such projects with a contnetogs)licensed pursuant o Ne Contractor's
Lkeve Taw.
❑I am exempt under Sec. .B&P C for Nis rtamn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affient under Penalty of perjury arc or the following declarations:
I have end will=Amain a Ccnigcom of Consent to self-Inure for WorkersCompen-
atien,a provided for by Section J]BII of Me Labor Gude.for the performance Of thC
week for which this permit is issued.
❑1 Mae and will maintain Workers Compensation Ivufmce.As acquired by Section
7]00 yyyf the Labor Cad a for Ne peRomtmcc of the rk for wM1ich Ibis pennil is Issued.
M_y�9f to mo Co f (Ivo nee martins d limy numbcrart: 2
�0 r P e No.: O� 6 le v
\ 'R FICATEOF:XEM ON FROM WORKERS'
COMPENSATION INSURANCE
(This¢conn need not he completed If the permit Is for one hundred dollars(SI(g
lir 4sa)
1 certify Nal in the performance of Ne work for which his Permit is issued,I shall not -
employ any person in my maner m as to he=m,subject to Me Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become mhjact le the Worker's Compensation provisions of the Labor Code,you mug
Oforthwith comply with such provisions or this Permit shall be decreed revolmd.
ti` CONSTRUCTION LENDING AGENCY \
I hereby Arms that Neve is a convection lending agency for de,perfonnem:e of
x r7 the work fur which this permit B issued(Sec.309'f,Cih,C.)
7] Under',Name
Y z Lenders Address
7
J Q I certify Na 1 have with
this city
and coon and dYre Net the above sus matiun to
J. coned 1 agree ct comply with y city m0 courtly ntdinantts and cute laws r upon
to
� building construction,and hereby euthorim representatives of Nis city to corer upon Nc
NG aMve-mcn0aned property foremnifyi anpurposes.
r (Wc)agree to ave.indemnify ad keep harmless the City of Cupertino against
Iq liabilities,judgments,casts and expenses which may in any only accma against aid City
J z mPPLn ICANTeof the UNDEgranting or ST Nls Permit.
ND WILL COMPLY LTH ALL NON-POINT Issued by: Date
0.CER ULATIDN$. A
1 R 6 Re-roofs
nature of AppllcantlContralor Oe
HAZARDOUS MATERIALS DISCL6SURE Type of Roof
Will Ne applicant or future building occupant area or handle haaedous material
As defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
�-
rate.Section 25532(.)FAll roofs shall be inspected prior to any roofing material being installed.
❑Yea
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 Mardous air contaminants As donned by the Bay Area Air Quality Management all new materials for inspection.
Wier]
❑Yea IGrvu
I have read the haadous materials requirements under Chapter 6.95 or the Carfor.
MIA Health&Safety Cade,Seclitms 25505.25533 sari 1.1 on Wnd Ng ifdte build
d nenOY have a ren t is my responsibility ton 'fy Ne YrLmy 'rcmc m ri m WresonsbilityC racup.nignature of Applicant Date
neronuthorivnd egen, 4 All roof coverings to be Class "B" or better
i CITY OF CUPERTINO v 7 0
V FURNACE/AC 6
OUPERTINO PERMIT APPLICATION FORM
APN# Date:
? ! 3 163
Building Address: I S r� C L 1_ rk 0,
Owner's Name: Phone #:
le LALd
Contra nn Phone: License#:
Contact one: Cupertino Business License#:
; � yew z�--o 331
Building Permit Info:
Bldg ❑ Elect Lr Plumb ❑ Mech L7
Job Descriptio44 4- .G /
rY�I,J '''urnJc�cL
Residential Commercial ❑
For Residential Installations:
Attic ❑ ls` floor 5 2"d floor❑
dhere to min set back requirement❑
or Commercial Installations:
Replacement same wei t_❑ Additional weight (structural calcs) ElStructural Calc ations required for new installation
El
New instal on Planning Approva a uired ❑ _
Cost of oject: Q, Type of Constructio OccupanA71r '7
Strapped atform ❑ Bonded ❑ Sq.Ft. Floor Area:
i
New Location ❑ Replacement
Qty. if
Ap Ii. bl Fee ID Fee Descri tion Fee Group
BENERGY Ener BUILDING
BREEMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cf n MECHANICAL
BREMAIRHAN AJC 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
BUSLIC Business License BUILDING
# aS�