03090167 g'CITY OF CUPERTINO 'x�"+' �'%r4
BUILDING DIVISION PERMIT XON TRACTOR4INFORMATION ''
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BLDING ADDRESS: _ A B S HEATING & AIR COND PERMIT NO.
f'
OWNER'S NAME: 334 SHAMROCK DR PERMIT ISSUE DATE
KATT-Ty 1-11
9'12
"E' (408) 238-7178 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
joo LICENSED CONTRACTOR'S DECLARATION
wF Ino55by a((((firm that
I am licensed under previsions of Chapter 9(commencing lob Description
?Z`uf with Section g00lls a(DivisionJo(No Businom.0 Pmfcuiom Codc,end In,hear.is
N in full fo¢eypl�ffectC_Z0d.C ✓lt
ILl? Lice"'Ifas 0P^^ Carlo ( 7� REPLACE FURNACE, ADD A/C 6 �'w ��®
Data Y ✓ Contracto . ■.YF+�
QF[ITECTS 0 ATION
i �/ Iundcremd p ,,gghhWW//Illlmusedespublicrecords OCT 1 3 2003
ayU �=
�H Lncnud Pmfosuon 1
s g Oat I am exempt
from
DECLARATION
i 0 1 hereby affirm that 11, eaempt!rum the Contractor's eLicense Ac Law for the �'��,•
❑O following sawn.(Sadao]BJLs.Buafcssandmpr Professions Code:Any city nrcounty
7$ which,requires a permit re cnnstwct, idle improve.Jemoluh,or repair any swctme
d y pnonn its fused punlsu¢quinvhovisiosOf for wchpermitmicense aw(Chapter9
sm
thathe is mecing wit Pursuant 7to the0l Provisions nhhc Contractor'sBusiness
Sq.Ft. Floor Area Valuation
Z OF
(commencing he is exemptb Sectio n,and f Division r fl al Rosiness and Imrasson.Any
Cade)or
Net he is exempt Nomfrom and Ne buts far Ne alleged exemption.Any vlbadon of 31629032 . 0
Section]031.5 by any applicant for a permitsubjeen the applicant to a civil penalty of APN Number Occupancy Type
not more Nen I.hundred dollars(5500).
❑I.as owner of the property,or my employees with wages as their vole compensation,
will do the work.end the structure is not Intended or offend ro,me(Sec.7044.Business — ROUGH letw"j&,actions
and Proamong Code:The Camncwrs License Law dors nal apply w an owner of 3 03 - ROUGH MCNI AL
property who builds or improves Ihenon,and who does such work himselfor through his
own employ=.provided that uch improvements sa not intended or offered for salc If, 304 — ROUGH ELECTRICAL
however,the building or improvement Is mid within one you of completion,the owner-
builder will ban the burden or proving that he did not build or Improve far purpose of 505 - FINAL ELECTRICAL
"I`')' 507 - FINAL PLUMBING
co 1,as owner of project
property,serexclusivelyBusiness
nd contracting with licensed contractors to
come,La Nees not apply to
wneror andPywhobuidsatIThe eanthwwr:u. 508 - FINAL MECHANICAL
whoa Law dmf not loan owner of draper(who builds os improves Contractor's sed _
who
ns contracts for such projects with aconlnnor(s)Hawed pursuant m the Contnnoh
License Law.
�I am accept under Sec. .B&P C for this noon '
Owner Dan
WORKER'S COMPENSATION DECLARATION
I herby".under penally of perjury am of de following decimations:
I have and will maintain•Ceniicme of Consent to self-lasure for Worked Comr n.
tion, r hick this
far a is
issued.3]00 of Ne Inbar Cade,fm Uu perfarmana of the
ork for which Nb permit is isaued.
❑I have orb will maintain Wwkcr's Compensation Insurance,u Intuited by Section
3700 of the Labor Code,for It performance of the rk for which this Permit Is issued. '
My Wor a LCso�mPemation Iawnme artier eM ry numkrert: ^'
(A N y No.:
CERTIFICATE OF EX ONFRO WORKERS
COMPENSATION INSURANCE
(Thu soctan need not becomplend If the remit is for am hundred dollars($100)
less.)
I certify that in the perrmmance of Ne work for which this permit is issued,I shall nm
employ any perien in any manner an as to become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
beeome subject to the Workers Compensation provisions of the Labor Csbe,you must
.J O forthwith comply with such powisiam or this permit hall be deemed revoked.
Z "" CONSTRUCTION LENDING AGENCY
N.E 4 I herby arf rem NU thea Is a construction lending agency for du ce perrurmmof
> the work fur which this permit is issued(S..30117.Ci,C.)
GQ Lender's Name
.7 z Lcndees Address
U O I artily than 1 haw rad Nis IPPlleatian and s.M Nat the above information is
Iy F conal 1 agree w comply with all city and county Ordinances and auk laws misting to
O U building construction.and hereby authorize representatives of this city to enter upon the
shove-mentiuned property for imPeeno purposes.
(Wc)agree to save,indemnify and keep humless the City of Cupenina against
tivl liabilities,judgments,costs and expenses which may in any way accrm against mid City
U7 in consequence or the granting of this Permit
s7 APPLIC NT fJN �tSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
so NS TQ1N5. ���
�A, O Re-roofs
Si
C.of ApPlicw HAZARDOUS
Data
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Will No applicant or(Muni building occupant store or handle Health a material
u one.
Scd by the 32(.)Cupertino Municipal Code.Chapter 9.12.and the Health w0 Safety
I
dc. 0 en:ss32(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
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 haysbous air connminanu u dc(ined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes PNO1 have toad Ne humoroVuss materials requirements under Chapter 6.95 of the Califor-
llcalth&sofa Cade.Sea '25505,35533 and 25534.1 understand Nm ifthe holding rtcn h a Meant Not it is my responsibility te nod I the oucupant or Nc
ow is mel mIphorwissuutccoracenrwauoroc-w Signature of Applicant Date
. 6
All roof coverings to be Class"B" or better
04 agent Dom
i�
CITY OF CUPERTINO6 3 0 01 Z/?
FURNACE/AC
CUPEkTOF
INO PERMIT APPLICATION FORM
APN# r7 Date:
rC>
Building Addr ss:
Owner's Name:KAT-Ry
wT-R I Phone#:�7
77 ,0�3s-
Contract � � iLicense#:
or*,.65. UP, Ltd�0-)b
Contact: Phone: Cupertino Business License#:
,U A-I I
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: rU C �. �D 9/C 4ci
Residential JR Commercial ❑
For Roidential IaU llations:
Attic N. ls`floor 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calcul5iGns requqed for new installation ❑
New installati lannin A oval Required
Cost of Proj ct �()U Type of Construction Occupancy, ou
c
Strapped -0n-Platform. Bonded ❑ Sq.Ft. Floor Area.
New Location ❑ Re lacern " �2- -3 2(/vr
Qty. if 4 a � F
Appji4We Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
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 BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
J BPLANCHK Plan Check Fee BUILDING
BUSLIC _ usiness License BUILDINPI
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