05110029300
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CITY OF CUPERTINO
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BUILDING DIVISION PELT�l�l'!•Q�1"""^lr�
BUILDING ADDRESS:
AAA FURNACE & AIR CONDITI
f�t;G�05110029
OWNER'S NAME:
PERMIT ISSUE DATE
ANNA DIBONO
1719, qTQNR AITP
in /n:7
NE:
SANITARYNO. CONTROLNO.
(408)293-4717
ARCHTIECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
hapten 9(comm
that 1am licensed under pmvwansofs Chapter
am lithe
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Job DOSC0PU onam
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my ficaml.s
with SectmnbyX8M tvwI Busircv and Professions nm4
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REPLACE FURNACE (2).
Ytj'1ts
Lkenm Clan Lk. N
Dan Conlramof
Hf1ECrSDECLA A N
1 Owl be umd u maom
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�I.Iv �
2005
mu erwnd MY puns public
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Licensed PmfraYanal
OWNER-RURDERwn
Me CATION
1 hereby a1Rnn this 1 am exempt from the Conhnetor's License law far tlw
�Ie
ftnfl
following mason. (Section 703 1.5, Business and Professions Cade: Any city., county
ftVal.lt/,7t 0
which regulon a permit w construct alter. improve, demolish, or mPale my sun mne
ijaJd
pine m its issuance, atm requires W applicant for such Permit he Ole a signed swcmcm
Law 9
Sq. Ft. Floor Area
Valuation
that be is licenced purammt cede Provisions of the Contrmw',rice=(chapter
(commencing with Sen)m 7000) of Division 3 of the Business and Pmfessians Coda) or
Out he is asempt Unref arm and W basis for the alleged emmPtion. My Molwon of
IAIbr O 0
Occupancy Type
SeNan 10313 by any applicants for a permit subjects W applicant m a civil penalty of
not mart them Rw hundred do1Ws (S.SOR).
❑ 1. u awmf of tilt property, or my maployeas with mass o their mlecampewtion,
Required Inspections
will do the work, And Me =turn ts not intended ar ancmA fmaak(Sec. 7041• Bud^...
and Pmresdam Code: The Cortraseala License law dean ret apply m un owoer of
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property who builds ar improvan thenen, unaware does such wok hivuelf ar thresh his
awn employers, provided Nu such improvements art notin ended oroffered for We. if.
'
hcomm, the building or Improvement is sold MWn am year of eamPletim. the awm-
Wilder MR have the burden of proving that be did ret bum ar hnprow few Pur oe of
isle.).
❑ 1, u awasr of the property. am exclusively contracting with licensed contractors m
construct W pmkan (Sec. 7044, Business sul Rofesdons Cade:) The Coetraem', U.
.cess raw dots am apply m m owns of prepmy+5m huiles or lmprowa Nem., And,
whomntectsfarsuchpmjcm Mmamna or(s)IiemmdpusommmtheCmumtoes
License taw.
❑ Iamemmptundersec. .B&PCrarthumuon
ner Dan
WORKERS COMPENSATION DECLARATION
I hereby affirm ander penalty of perjury ane of W folmwing deciarulans
1 ham and MII mumu. aCardfiWe of Concent m self mune for Warlece, Compen•
on, u provided for by Section 3700 of the labor Cade, for the performome of W
,
rk for which Wa permit is hsued.
130100
I haw and will maintain Worker's CompensWon insurance, u required by Smion
of tie labor Code, far the performance of the wok for which this pewit a issued.y
Worker, Compensalon rte. arda and Policy number ase:
rrier. Policy No_
CE FlCA OF NFRO 0 ERS'
COMPENSATION INSURANCE
COMPENSATION
Clbissection min net be romp AAd Rule Intuit ts forore hundred do0asa(SI00)
or las.)
I certify that In the performance of W work for which this permit le home, l shall not
employ any person In my mmmran u te became abject to the Workers' Compensation
I. of C3]if..iL Data
Appllunt
NOTICE TO APPLICANT. If. after making this Cenincam of Exemption, you Mould
become subject m the Woroces Compensadm provisions ar me labor Cade you most
fanhMW comply with such provisions or this permit Sall W demand revoked.
CONSTRUCTION LENDING AGENCY
I hemby anion this Vert 1, a core dnn lending agency far the performance of
me wrk fur which his pemtk ts issued (Sec. 3041. Civ, C.)
Lender Nam
Lender Address
cerlfy that I have raid this Application and sum this tha show infamtadon k
carted 1 nem to comply with all city and county ordinances and awe taws mining m
building construction, and hereby authorize repreumaRm of anis city mentor upon W
shove -mentioned property for Inspection purposes
(Woe) agree to saw, Indemnify and keep harmless the City of Cupertino asainsl
liabilities. judgmcnu, emu and expenses which may in my sty amus Against said City
in consequence of the grating of mk pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date i -6
SGU CE REGUyyAATIGNS.
=
lLufV'_"= !
Re -roofs
Type of Roof
{nature -of Airpliam/CanuaafterRAZARDOUS MATERIALS DISCLOSURE
Will the stareor handlehazeNousmanrw
Cooccupant
AsIdetinet by tie Cupertino Muucipal Code. Chapter 9.11. and the Nealm and Safety
CupertinoMunicipal
.de. section 13331(.)7
All roofs shall be inspected prior to any roofing material being installed.
Mau No
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicent or forum building occupant use equipnmt or devices which
MIL hsmotious air contaminants m &flncd by me Bay Man Air Quality Management
all new materials for inspection.
❑Yes �NoI
haw mad tie mucerdhns materials requirement, under Chapter 6.95 ofine Califor.
e Health& SafetyCada Sections 15505,13333 and 25534.1 understand ren lore buildingocs
not currently haw • mount ren it k my mpo.dhility m notify the =upon, or W
qui�)iAcros b.Kh�moust be�.1int arm inumm.raccrufNamoracoprcy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
oTlafaam`r �
•
•
I am not using any subcontractors: _ A-4� 8f 2 ^-'' /I - 2 -o-r
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
Date
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
Owner/ Contractor Signature
Date
CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
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N #
Energy
b
BREMFURN
ng]Ad�dress•
L
MECHANICAL
Z
A/C Unit > 10,000 cfm
Owner's Name:
Phone #:
A/C Units <= 10, 000 cfn
MECHANICAL
Contractor:
License #:
%lafop?/
Contact: /, �
Cupertino Business License #:
(r �
BUILDING
Building Permit Info:
Elec Permit Issuance
Bldg ❑ Elect eL_ Plumb ®
Mech
Job Description:
MECHANICAL
2-u O,E�o �'o c
)
BTc
Residential Commercial
BPERMFEE
For Residential Installations:
BUILDING
Attic ® I` floor 2"a floor ❑
Plan Check Fee
Adhere to min set back requirement ❑
BUSLIC
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction:
Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
ADDlicable
Fee TD
FPP T)Pcrrintinn
FAA !":,•..
BENERGY
Energy
BUILDING
BREMFURN
Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfn
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
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
l 7 i a-7