05020162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT SCONTRACTORANFORMATION
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BUIL DING ADDRESS: A B S HEATING & AIR COND PERMITN'65020162
OW NER'S NAME: PERMIT LSSUE DATE
NE: SANITARY NO. CONTROL NO.
(408) 238-7178
ARCHlTECT/ENGTNE
2 8—
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
LOO LICENSED CONTRACOR'SDECLARATION MJbDescription
I hereby affirmo
shat I am licensed under provisions of Chapter 9(commencing with section7(sl of Division 3 of the Business and Profession Code,and my licerec is
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jin"llto=and er(ycl '�` llG} �(� FURNACE REPLACEMENT
lg= License Class ff IC Lk,M
?;-p Dow Z`1A.UG-' cmdracWf
ARCHITECTS DECLARATION
< I understand my plans shall he used as public meards
�aU
3 o y
Licensed Professional
OWNER-BUILDER DECLARATION
S I hereby affirm Nal I am exempt from On Contractors License Law for the
p o following mason.(Section 71131.5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish.or expair any structure
HZi prior or its issuu¢c,also requiacs the applicant for such permit to filo a signcdauWmcnt
< that he is licensed pusoanuothe provisioasoftheContractor's Liaenselaw(Chaha91 Sq. Ft. Floor Area Valuation
b,FO (commencing with Salton TOM)a(Division 3 of She Business and PfoficadCfa.)oi-�
R.3$ that he is exempt therefrom and do ha¢u for the aIlagcd exemption.Any vi.11 I . of -
Scction]WLSby any applicantfor apermit Subjects theapplianuoacivil int
not mom lal p� /0!rBI3u'1&e00 Occupancy Type
Nanfiw hundred dollars(5500). /�
(]L is owner of the pmpeny,m my cmployca with wages as tbcrr, lc int pensatlon, . !'/ f�+�
willdothework. ndthunctuwisrmtlnwwedmofftr forsak(Sa.] Bmsincss \ f.,#,Re wired Inspections
and Professions Code:The Coruscates License Law docs not apply at nww�er of . / D eq P
propeny who builds orimproves themon.and who doessuch work Glielfor duough hu, '� r
however.she building
i or improvemimpm old witinnos year
olAmicumn,(tar ownes,
builder..she building or improvement is sold within one year of c prove f r the owner-
builder will have use burden of proving that he did not build or Improve for purpose at
❑1,as owner of the property,am exclusively contracting with licensed contractors to
comtmes the project(Sec.7n44,Business and Pmfoual Cede:)The Comments's Li.
cease Law does not apply to an owner of property who builds or Improv themon,and.
who contract,for such projects with a eonoacmr(s)licensed puavam W the COmnemh
License law.
❑1 am exempt under Sec. .B&P C for this moon
oame, Date
WORKER'S COMPENSATION DECLARATION'
I hereby affirm under penalty of perjury oro of Or following declarations:
1 have and will maintain a Cenificae of Comers to self-insum for Worker's Compen-
137M
tion,as provided for by Section 3]00 of the Labor Code.tar the pedonnonce or the
rk for which this Permit is issued.
1 have it will maintain Worker's Compeaadon Insurance,u acquired by Section
of thc labor Code,for the performance of the work for which this permit is issuedy WorTkg/i��s Cn1q��Inpeasauon Irurance easier and Policy num rart:rier.KC 11�rt/U✓) I n l Polley s
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becmnplemd Kthe permit is form=hundred wllars($IW)
or MOU)
I certify that in Ne Performance of do work for which this Permit is issued.I strait and
employ any person in any manner in as m become subject to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making Nis Certificate of Exemption,you should
become subject m Nc Worker's Compensation provisions of the labor Code.yam must
.JO forthwith comply with such provisions or this Permit shall to desired revoked,
O CONSTRUCTION LENDING AGENCY
;: I hereby affirm that Vert is a construction lending agency for NC Performance of
C the work for which this Knont is issued(Sec.309],Ci,C.)
WCl Leadcr's Nvnc
6. landefb Awacss
J O 1 witify that 1 have mad this application and same that the above information is
Is. caeca 1 agree toc comply with all city and county ntud nam and SUM laws r Upon t e
0(J alsomngcotioned construction,Lord hereby authorirzrposea wsiva of Nis city so en¢r upon the
0. ahovc(W tion agree
to Saw,
for inspection t keep
hu
0.V) (We)grot to ave,indemnify and keep harmless Or City m,against Said
against
F' Z incoitigmnc me ns,costar Lord ex this permit. may inany way accroc ageinstsaid Cisy /—
f>z A APPLICANT
of dere UNDERSTANDS AND
per mit. v 2- . O
^ APPLICANT ULATIONANOS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
U REGULATIONS
(_\_ 2- ?Si!-C)@ Re-roofs
Signature of ApplicanUCoomcmr Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future building Occupant alone or handle haraamous mawrial
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ewe, enzss3z(a)?
0 yes L Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit ba,tSmous air contaminants as dcrned by the Bay Area Air Quality Management all new materials for inspection.
lia
isuiCO - /
Yes q.V9u
I have mad Live Waardous materials Requirements under Chapter6.95 of the Califor.
Health&SsferyCwe,ScNmu25505.25U3 and 25534.1 undommand thtifthe Wilding
oes not curscmly hoc a¢rant Nat it u my mxpersihility,W notify the Occupant of the
gmim ata hath an me,pdar0issuance ofaComfiawofGentian Signature of ADate
Ow roranmoriredagent Date All roof coverings to be Class"B" or better
p, CITY OF CUPERTINO
FURNACE /AC OS o�� �--
CITY OF
CUPERTINOfn P-7E4RMIT APPLICATION FORM
APN # Date:
Building Address: �
CLC-44o
Owner's Name: -f6 Phone It.
Contractor: � License#:
E�n�C ��4i/� l �
Contact #:
Tkpe la�ll Phone 2-3b --7178'
Applicant/Contractor:
Building Peimit Info:
Bld Elect lumB e
Job Description: /n� ,, rr �99 �
Residential: ) ' e xmiq-�h Lu r Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer:. Valuation:
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BREMFURN Relocation of 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 BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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