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04050115ypZ 00 Ig n�Z z�c t « 3yu +_or^ �p0 ssi9 .5 CITY OF CUPERTINO"-=+;kr�n BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .:a.t�a BUILDING ADDRESS: 02 COTTONWOOD nR ERMIT NO.4OS0I1S """'04050115 OW NER'S NAME: PERMIT ISSUE DATE MICHELL DONG ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGELECT' PLUMB MECH (� t� LICENSED CONTRACTOR'S DECLARATION Job Description 1 therreebOyQaffirm that 1 am licensed under provision of Chapter 9 (commencing $$ BMs ZM p Profruinn Codc. and myliccns is nifulr'fnrcp alftcffct REPLACE FURNACE /DUCT License ulna D.m Cun rA CONTRACTOR: DAYSPRING ENTERPRISES ARCHITECTS DE TIOt 1 ulitmund my plans shall he used as public ..,its Licensed Professional OWNER -BUILDER DECLARATION I hacby affirm that I am cxcmpt from that Contractor's License Low for loo fallowing coach. (section 703 1.5, Business and Rofecdon Code: Any city or county which requires a Permit to convect, alter. improve. demolish, nr repair any iwcturt prior to its issuance. also mquims the applicant foe such Permit to file a signed mita menl that he is licensed pursuant to the provision of the Commcmn Liecnsc Law (Chapter 9 Sq. Ft. Floor Area Valuat$4340 (commencing with Section 700ff) of Division 5 of the Business and Professions Code) or that he is exempt thcmffom and me basis for the alleged exemption. My violation of APN Number Occupancy Type Section 7051.5 by any applicant for a Permit subjects the applicant m a civil penalty of not mom man Gw hundred dollars (5500).- 36918008.00 ❑I, u owner of the property. or my cmPloycea with wages as mein sole mmpenmun, Required Ins will do the work, and me structure is not intended or offered foraale(See. 7044, Business and Professions Code: The Contractors LicensLaw docs not apply W in owner of ee q p ections property who builds or improves theroon, and who does such work himself or through his awn employes, pmvidcd that such improvements are not intended moRe ed for We. If. however. the building or improvement is said within one year of completion, me owner- j� n builder will have the burden of proving that he did not Wild or improve for purpose of WC) 1, u owner of the property, am exclusively contracting with licensed economists 10 MAY 2004 convect the project (Sec. Wks¢. Business and Prof eesio s Code:) The Comracmr's U. 20 cense law docs not apply to an owner of property who Wilds or improves thcomm. and who contrace, for such projects with a con"Ctor(s) licensed formation t0 me Contractor's License Law. ❑Tem exempt ..our Sea .B&PCfor this moon BUILDING Owner Dau WORKER'S COMPENSATION DECLARATION 1 hereby aRrn ander punchy of perjury on of the fallowing declamations: - 1 haw and will maintain a Cenificam of Covent to self -insure for Workout's Compere ration, as Provided for by Section 5700 of the labor Code, for the performaee of the work for which this permit is issued. I haw and will maintain Worker's Compensation Insurance, ss required by SeCtion 5700 of the Libor Com, for the performance of the work for which mu permit is issued. My Workeri Come usation Insurance carrier and Policy number am: M r. Policy CERTIFFCATE ON ORKERS ' • COMPENSATION CE (Ibis section need not W completed/if the Permit is for mol undmddollart ($100) or less. 1 Certify that in thepc ormanin of the work for which this Permit is issued, I shall not employ any perso i ymannersoum,�bb{ryy��nmy�e_ a tWWorkcu'Compensation Laws of Califo^�� ateTrT1 U N TO APPLICANT. IL after making this Cenincam of Exemption, you should b c subject to the Worker's Compensation provisions of the IaMr Cndc, you must forthwith comply with such provision or this permit shall W deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a Construction lending agency for the perfurmance of me work fur which this permit is issued (Sec. 3W7, Civ. C.) Lender's Name - Louderi Address I certify mat 1 have read this it,licatirn and sats than de show information is correct. I agree to comply with all city and county ordinances and sum laws misting in building convection, and hereby authorim mprnenmfim of this city to enter upon the above- (We) greeed to crty forinspectionpropot keep hs. (hoc) agree to saw, indemnify and keep n, an the City of C against j IiebiliOes.J cots, casts and expcnsca which may in any way accme againm said City in Sam,, in conseq c a the granting off his peemic APPA NT U DER pS ,�;N WILL COMPLY WITH ALL pen rplNT Issued by: Date 5 C RE LATIO �� Re-roofs Type of Roof /}I -K///) G -- A-- 05-1 Signature of Applicam,Conlractor Dau HAZARDOUS MATERIALS DISCLOSURE Will the applicant or rmuro Wilding occupant mom or handle bvardom material as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety ode, Scetion355B3(o)? ❑Ycs *. All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding occupant ne equipment or devices which mit ha menus air cuntamimmes u defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Ycs AN. i Ihawmadmehmardlmsmxmfialsmquimmentsunser ChaPmr rfthe Califor to.I lLh ctyCodc.Socti.25505.25533 am12553a. l onmrsuM that Wilding 1101 C Ply naw 0lenanl 111]1 it h my mrPanln1111Y b Mdly 11e 0.e 10( tie req a Leh st metpd.,toiasuoneeof. ccoificateorOceapan Signature of Applicant Date G S All roof coverings to be Class "B" or better Owner or authorised agent Date CITY OF �UPEkTINO JOB Buil Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 t I am not using any subcontractors: . Signature Date Please check applicable subcontractors and complete the following information: ,wr/Contractor Signature 1 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass/ Glazing Heating 5' Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile zj 5z- -G Date CITY OF PERTINO CITY OF CUPERTINO FURNACE/AC O PERMIT APPLICATION FORM 0- CD S� APN #� % OD� / Date: — _D r L Building Address: BUILDING CA O wv BREMFURN Owner's Name: Phone #: - BREMACOVER Co actor: Phone: '„-i-I - 2y32 License #: g35S vi .2 BREMAIRHAN Contact Phone:Cupertino Business License #: BREMRECEPT Building Permit Info: ELECTRICAL Bldg ❑ Elect ❑ Plumb ❑ Me ❑ Seismic Fee Res BUILDING Job Descriptio . BSEISMICOM v BUILIDNG Residentia ® r❑ EPERMITFEE For Residential In tallations: El IN ❑ ELECTRICAL Attic I" floor 2"d floor MPERMITFEE ljk�dhere to min set back requirement ❑ MECHANICAL PPERMITFEE 11por Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ PLUMBING Structural Calculations required for new installation ❑ J BPERMFEE New installation Planning Approval Required ❑ BUILDING Cost of Project: Type of Construction: 7F Occupancy gr up Plan Check Fee BUILDING Strapped ❑ On Platform ❑ Bonded Sq.Ft. Floor Area: New Location ❑ Re lacement ® 3cj Qty. if ApplWa e) 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 Plumbing Permit Issue PLUMBING J BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business Licen e BUILDIN