03080078 6AD
UPERTINO �. a 3ys,�,g"u
DIVISION PL`RMIT `-aCOT �: OIl�'INI!��lYlll�lONr
SS: A & H HEATING PERMIT NO03080078
770 CHESTNUT ST PERMIT ISSUE DATE
S EMO (408) 279-0722 SANITARY NO. CONTROL NO.
INEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSEDCONTRACfOR'SDECLARATION JobDescri tion
I 1 hereby affirm Thal I am licensed under provisions car Chapser 9(commencing p
with Se do 70r10)nf DiNalon3.rdA incuamcpmInesiont Cole,andmylimarick
in Tull once REPLACE FURNACE & A/C, 200 VOLT CIRCUIT
j q Z Licen '�
Da¢ Ctractpr
'\/ ARC TECRLA ATAN
I < undcntaml my plans shall be.2 public records
)yU
08t; Licensed Professional
y� OWNER-BUILDER DECLARATION
f I hereby affirm Nal I am exempt from the Contractors License Law for the
D D following reason.(Section 7031.5,Business and Pmfessioa Cc&:Any city or county
5$ which requires a permit H ennsuuct.alma improve,demolish.car repair any structure
-xi prior to its issuance.also resume:the applicant for such permit to file a,igncd su¢mcm
q5FF< Nat he is licensed pursuant to the provision Of the Common'.License Law(Chapter Y Sq.Ft. Floor Area Valuation
C3� (commencing wi th Section 7")of Division of the B usincu and Professions Code)or 36937010 . 00
It Net he Is exempt therefrom and d¢bests for the alleged exemption.Any violation of
Scctlon 7031.5 by any applicant fon permit ubjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom than live hundred della.(SSW).
❑I,as owner of the property,or my employees with wages a their sole compensation,
will do the work,and is not lnundd or offered for sale(Sec.7014.Business — Kuuuki
and Professions Code:The Contractors Limnse law does not apply m an owner of 3 03 — ROUGH t10ns
property who builds orimproves Hereon,and who docssuch work himself ortirough his f�
own employees,provided that such improsemenu ue not intended or offered for side.11, 304 — ROUGH ELECTRICAL
however,Ne building or improvement Is mid within one year of completion,the owner.
builds will love Ne burden of proving that he did not Wild or impre.for pu pose of 505 - FINAL ELECTRICAL 2/
507 - FINAL PLUMBING
❑I.as owner of the propony,am exclusively convecting with licensed contractors to 508 - FINAL MECHANICAL
construct the x4
project(Sec.70 .Business and Profasions Code:)The Comne.rt Li
come Law does not apply H an owner of property who builds or improves themon,and
who contracts for such Projects with a contractor(s)licensed pursuant to the Connote,
License Law.
❑I am exempt under Sec. .B&P C for this noon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby a(f sur under Penalty of perjury one of the following declarations:
1 bat and will maintain a Cen1Enr,of consent to ul6in,Woc fm Worke6Compon-
satlon,as provided for by Section 3700 of the Labor Code,for Ne Performance of the
work for which this permit is issued.
❑1 ban and will maintain Workers Compensation Insmsem.a required by Session
3700 of deo Labor Code,for Ne Perrin a fda work fnrwhich this peris
mit I. sued.
M Wo k e C n tion loaunq e c and Poltcyylu cr rt:
a ' )
C Polity No: v
CERTIFlC OF E FROM WORKERS'
COMPENSATION INSURANCE
(Mu section need bet Mcomplawd if the Permit is forone humboddollan(SIMI)
ar ka)
1 certify that In the perrmmaneo of the work for which this permit is issued,l Het]nut
employ any Person in any manner an as to become subject o the Workers'Compensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject to the Worker's Compensation previsions or Ne Lnhnr Code,you must
0 fmtirwith comply with Such provisions or this permit shall be deemed nwntrd.
�� CONSTRUCTION LENDING AGENCY
1 hereby slrvm that them lar consvuctin r lending agency for the performance of
x 7 the work fur which this permit is issued(Sea 3097.Civ.C.)
11 Q Isnact. Name
2.z London Address
J Q 1 comfy that 1 have read this application and State that the above information is
y f"
building
I gree m comply with y city and county onttnanaf and tuts laws catrelating to
C.j ahowngcon)vectioaana herebyauthoma.presenutias of Niuiry to enter upon ties
N gL ehovc(We)
ed gree to property for inspection an keep hi. of
.w (We)agree soave,indemnifyandkeep harmless the Cityruagainit aid City
' fZA incoisequeneof s.thecosuang of this expenses which may in anyway accrue against said City
J �-^ APPLICAeNTeUNDERSTANDStAND�tt.
LL COMPLY WITH ALL NON-POINT Issued by: Date /
OU EREGULATIONS.
Re-roofs
m me of Applic.nUCoriumtor Oem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or Monte haralloa material
a defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
sae,Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building Occupant use equipment ordcvices which If a roof is installed without first obtaining an inspection,I agree to remove
it haamous air contaminants a def the Bay Arca Air Quality Management all new materials for inspection.
vicR
❑Yes Nu
1 have mW the huvamnus materialsrcq.immmts undo,Chapkr 6.95 of the Cabou.
nia Heath&SafoyCoac,SeNmts 25505.25533 and 25534.1 understand that if the building
does not currently hoe a tenant,that It u m rcsP rmbdq atify occupant of He
qui. cnuwhkhred met Prior be are rdOcate Signature of Applicant Date
own aumnriaaaa eat Da. All roof coverings to be Class"B" or better
CITY OF CUPERTINO 7
FURNACE /AC
V:UPEkTINO PERMIT APPLICATION FORM
,. •APN # 36q -37 - oio Date:
Building Address:
dQ36R CLIF--DW
Owner's Name: Phone #:
loopee o� 3- X69
Contractor: 9 I' License #30 5IV7
.f Contact: Phone#: i
F1 i
Applicant/ContractorQQ,c
Building Permit Info: T` r17
Bld lett Plumb Mech
Job Descriptio
q; ..
Residential: R P
Commerial:
Sq.Ft. Floor Ar a: $/Sq.F't.:
i •
Architect/Engineer: Valuation:
` ype of Construction: Occupancy roup:
{' Qty. if
Alit Fee ID Fee bescri tion Fee Groupj
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 I
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILII�NG
2—