04030018 CITY OF CUPERTINO - ' -- --—
RulLnlrvc lavlsloN PERMIT CONTRACTOR INF>ORMATION _
BUILDING ADDRESS: PERMIT N0.
04030018
la
WNER'S NAME: PERMIT ISSUE DATE
i WEEKS THFT.MA F. TRIMTR.R.NE:
SANITARYN '12 CONlAOL NO.
HITECpENGINEER: BUILDING PERMIT INFO
SLOG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONJob Descri tlOn
iI hereby affirm that 1 am licensed under provisions of Chapter 9(Commencing P5Section? )ofDivision Sofde Bysi9psand of.xxihmsC dC.mdmylicc se,is
'rt �mm! flefect.C? p X1 'Z.2S3–� REPLACE FURNACEj 'se Class zI Qw 0 49 Contractor c �u CONTRACTOR: LUKAS HVAC
ARCHITECTSD ATION q
�i I undersand W u nd my plans shall used public rccnrds MAR 1 6 2004
DyU
30l; Limnsed Profcsdonal
3 OWNER-BUILDER DECLARATION
1 hereby office that 1 am exempt from One Contractor's License Law for the
oBUILDING o f following mason.(Section 7031.5,Business and Professions Code:Any city dr county LWI
m r which requires a permit to cons ,.alter,impm c,demolish.Or ePwf any svuctme
FIaprior in its issuance.also requims the applicant for such permit to File a signed statement
Nat he is licensed pursuanun the provisions of Ne Cinumi License lsw(Chapter 9 Sq. Ft. Floor Area Valuat�l800
yHa (commencing with Section 7W)of Division 3 of the Business and Prollcul Code)at
c g_ that M1e u exempt thereftom and the baso for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number Occupancy Type
not mom than five hundred do1Wn(5500).
pl.uowner oidia propmr,ter Cor wployw wire wgesumein Cole compenvdon, 35904027 . 00
will dome work and this,swmue is not intended or offered for sale(Sec.VDU,Business
and Professions Cade:The Convactori License Law does not apply to an owner of Required Inspections
property who buildsor improve tMrmn.and whodoessuch work himselforthrough his
own cmplpyces,provided thmsuch improvements tae not intended or offered for We.if.
however.the building or improvement is sold within one yens of Completion,We owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
tile.).
;-cho
n owner of me property,am exclusively Contracting with licensed contractors to
son the project(See.70 ,Business and Professions Code:)The Contractor's Li
Law does not apply to an owner of property who Wilds or improves hemon,and
noacu for such projeca with a eontranor(s)licensed purauant to the Convenor sse Law.
exempt under See. B&P C fm this rtuon
r Date
WORKERS COMPENSATION DECLARATION
1 hereby aRmt under Penalty of perjury one of the following declarations:
aveand will ummum a CeniBe+te afCanscnt to self-insure for Warkeri Compen-
sation,as provided for by Section 3700 of me Labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inswance,as required by Section
37M of he LSWr Code.for the performan.of the work for which his permit is issued.
My Worker's Compensation Insuence Cosner and Policy number am:
Carrier. Policy NO, _
CERTIFICATE OF EKEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Ibis section need not W completed Utie permit is for enc hundred dnllan(5100)
or no .)
I cenify that in he performance of me mark for hich anis permit is somed,I shall not
employ anyP�rsan tp any mmncr5 u , Worlue Compnumme
Laws of CaltfoiMY Dat
NOT t P _
NOTIC T APPLIC NT.I dag,1M1' hn'!�.•di Exemption.you should
beco )ect to me orkei eom'=iu n provisiam of nC la W,Code,you must
.�Z foMwith Comply win such pmvuions of his Permit shall W deemed rewkcd.
Z O CONSTRUCTION LENDING AGENCY
�-. 1 hereby affirm hat there is a construction lending agemy for the performance of
C' he work for which his permit is issued(Sec.3)97,CO.C.)
LendcYs Name,
7 Z Lender's Address
J 0 1 certify that I have food this appliestion and sate that Oc above information is
Il. P eovctt I agsm to comply with all city and county ordinances and sate laws mlating w
0 building Construction,and hereby mdorixe epresenutivcs of his city to color upon he
r [31 above-medioned property for inspection purposes.
H gy (We)agree to save.indemnity and keep harmless the City of Cupertino against
h liabilities.judgments.casts and capemars which may in my way accroo against said City
in
of the
Permit. 07V
U? APPL CANTeUNDERSTANDSranting of nts D WILL COMPLY WITH LL 0 -POINT Issued by: Date
SOURCE REG NS. 3
Re-roofs
nature,of Ap liceint/Convacwr Dan,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future Wilding occupant stem or handle hmardous material
as defined by tW Cupertino Municipal Cod,.Chapter 9.11,and me Health and Safety
out.Section]553Z(a)?
Ye All roofs shall be inspected prior to any roofing material being installed.
Will the m'lhCant or mtore Wilding rempam use equipment or dcvicw which If a roof is installed without first obtaining an inspection,I agree to remove
it hurardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Disvia? v1N�
❑Yes \ A
I
M1avcmdadneha>aNnomaterials anctsundrd.95 ofine Califon-
nxHealh&Safety .Sons 25M.255)3and7553a.1 dermanddauiDWWilding
docs twt cufony how. emmc Nat it is
rj responsibility on Wary
occoDurt of ve
mtmo,nonts win sr' metp rte- nano„roe cenirwaw�f pm� Signature of Applicant Date
or anthnn degent - ` te All roof coverings to be Class "B” or better
' Community Development
10300 Torre Avenue
sm
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
$M TINO
Building De artment
JOB ADDRE Z l d •3� CD. Af cl C1I PERM
OWNER'S NAME: (i S PHO (v - $ O
GENERAL CONTRACTOR: (_ If r-,+C- FAX # — u 7b'r SK7
I am not using any subcontractors: 3 Z
Si ature Dat
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass / Glazing
y Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
°f
Owner/ ontractor Signature Date
CITY OF CUPERTINO
G�� . FURNACE/ACaffof
UPER-TINO PERMIT APPLICATION FORM
r
APN # 7 D Z Date:
} v j
Building Address:
-2— Co
Owner's Name: Phone /o 78s CD/
Contractor: r LA,( /�4 Phone��( _ �g� G��� License #: � la�
Contact: Phone: b Cupertino Business License#:
Building Permit Info: \
Bldg ❑ Elect ❑ Plumb ❑/ Mech
Job Description: )
nCie
Residents l Commercial ❑
For Residential Installations:
Attic ❑ 1" floor�2"a floor❑
Adhere to min set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New install ion Planni rove uired ❑
Cost of P 'ect: e of Constru do .� Occ an � p: �
Strapped ❑ On Platform Bonded-L] Sq.Ft. Fl—oo. ea:
New Location ElReplacement
Qty
,Appfig(ab$ 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING