03070118 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFQRMATTQN .
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BU ILDINGADDRESS: A & H HEATING PERMIT NO 03070118
A5 rnTTL')NWQQD ZR
• OWNER'S NAME: 770 CHESTNUT ST PERMIT ISSUE DATE
ONE: (408) 279-0722 SANITARY NO, CONTROL NO.
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CHITECTIENGINEER: BUIIDING PERMIT INFO
BLDG ELECT PLUMB MECH
4 iW LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby ef0rm IMI I am licansed u der provisions of Ch.
pmr 9(commendng
n< h Section 7=))Oloivisioh3orNeBu�,andPrufeuiomCOdc,mulmylpcenseis �p r1 n ,,qq
< im�ader L ?16,q FURNACE & ADD A/C, 220 VOLT 'CIRC11
_=`Z Licenu Lie.N
�et
Date ARCHnECused s�Ip] ,.RATION
Y I underttenJ my plans'hall k used%,rtcnNs JULJ lJ 2 9 200
uLicensed Pra1
='D OWNER-BUILDER DECLARATION BUILDING
l•11 g'O A1���
N IAV LD
E 0 0 I hereby M.a nl I I.S.eanmpl from 1M Contractor's C s e:Any c law for IW
O o whichfollow
al.a.(Salon R13 LBuchu and am.Prokr ar Cade:Any city nr.a.
Z county
� which requires•permit n uiral the alar,improv,dcmcruit t or repair any nmetun:
prior to its Sensed P also requires the visions for sech recruit License
s signed summcm
��<
that be ending wit pSectio 7to the")of Division
of the the
ndprofsso(ChapterCode)or Sq.Ft. Floor Area Valuation
(commencingwit thectiman and She
Div61on r theof al eged exempt on.Any
Code)or
.. Nn he u nempl Nertfrom and Ne buss for de alleged exemption.Any Nnlu(on or 36917045 . 00
Seed.7031.5 by eery applicant for a permit subjects Ne applicant m a civil pcmlly of APN Number Occupancy Type
not more dun Ew hundred dallart(5X10).
❑1,u owner of Ne pmpeny,m my employeeu with wages u deb sele campenution, ❑
will do the work.and thesndure Straus intended oro@red foraale(See 7014,Business, — g' ctions
and Profession,Code:The Camaseve's License Law does not apply to an owner or 303 - ROUGH M CHAN CAL
pmpenywho builds to
improwa thereon,and who does such work himrerorthrough his
awncmploym,provided lhattuch lmprowmemmarmt intended orofferad forsda.If. 304 — ROUGH ELECTRICAL
however,the building or improwmeht is sold within am year of completion.the comar.
Wirer will Mw lM burden of proving Nat M did not Wild or impsow for purpose of 505 - FINAL ELECTRICAL
"I`')' 507 - FINAL PLUMBING
❑Lasmvmrofct(Sec.7M,
4m exclusively contracting with limnedconaxm, t. 508 - FINAL MECHANICAL
Same La the Project(Sec..a. .a,of and Proresoow Code:)The Conwdor'a rad
came law docs Out to an owner of property who Wild,w improv Comon,and
who cpntmcu for such pmjecu with a conaantor(q lieenxd punwm m 1M Contrxsm'a
License law.
❑1 un exempt undo See. .B @ P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby M.under pemlty of perjury one of Ne following dedmdow:
I haw and will mainuin aCanificateof ComOnuo self-insum for Woftes Corsica-
ma.u provided far fes by Section 3700 or tM labor Code,for Ne pars'...ee of tW
1MyE373'5M
rk for which Ni,lcrmit is iuucd.
1 have and will maintain Worker's Compemitinn Insurance,u required by Section
of Is labor Code,for the performance of the work for which this ream 116 issued.
Worker's Compensation Insurances carrier end�yo/hcy n r
Policy No.:c!
CERTIFlCATE OF EXEMPI7ON FROM ORKERS'
COMPENSATION INSURANCE
(This seclirm need not W complemd lithe permit It throw hundred dollars(5100)
or leu.)
1 unify,Nat in the performance or the work for which this permit 6 issued.I shall not
employ any person in any manlier so as in become subject 10[be Workem'Compenutlen
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CenlBeslc of Exemption,you should
tacome subject in the Worker's Compensation provisions of the Labor Code,ynu must
OForthwith comply with such provisions or this permit Shall k deemed revoked
z CONSTRUCTI ON LENDING AGENCY
-{-+14 I hereby aRam that Ncm its comnctina lending agency for NC performance or
�i 7 Ne work for which this permit is issued(Sec.3097,Civ.C.)
W QLeaders Name
z Lender's Addmae
U 0 1 canify that 1 haw read this application and state that the shove information is
W F cancer.1 agree to comply with all city and county oNinanees and sate laws relating to
0U building construction,and hereby authorise mpraxnutiwa of Nis city In emu upon tits
W AWw-Fashioned Property rot inspection Purposes.
C. (We)agree to caw,indemnify and keep hannleu tM City or Cupenino against
V) liabilities,judgments,costs and expenses which may in any way scenic against mid City
t)7 in consequeacc or the Small all of this permit.
'a7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEGULA✓TIONS.
-4 Re-roofs
ssumd p0icam/Conuanor Oate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hamrdous material
as de0ncd by the Cupertino Municipal Code,Chapter 9.13.and Ne Hesllh and Safety
Code,Section 35533(4)? f— All roofs shall be inspected prior to any roofing material being installed.
❑Yes C1 No
Will She applicant or future Wilding occupant use equipment as devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haeradhus air wraminams as defined by the Bay Area Air Quality Managemcnl all new materials for inspection.
nricl7
❑Yee (�
1 hawreatl Ne M,udnmma M5, 5533mmentsunderwM 6.95orthc balding
does
r,ra. o,iti my m,pd3ubdity an hoary d nectar Wiring
docs ml cunently hew a tmanL Net h is my resPumihilitY m nndty tk nttupant of d,e
ai or birth most la,mctran, ance or.ccwc&Tor Occupancy. Signature of Applicant Date
Owner or authmbed agent Dau
All roof coverings to be Class "B" or better
CITY OF CUPERTINO 3 L�
FURNACE /AC U
UPEkTINO PERMIT APPLICATION FORM
APN # Alessi:
10Date:
,, 7
uilding ��s
Comm wpa pk,
Owner's Name: Phone #:
53 -7 6i
Conti-act • t/4 � G License #:301f �+
Contact: Phone #
-Applicant/Contractor.
Building Permit Info-
Bldg Plumb
Job Description: R1 I?- FEC ft-G(E_
Residential: — QL.% Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.
Architect/Engineer: Valution 5 5 90
e of Construction:
Yp Occup ncy Group: ,
Applice Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
i
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
:TBUSLIC
RMITFEE Mech Permit Issuance MECHANICAL
MITFEE Plut b n Permit Iss e PLUMBING '
RMFEE EBld Per it Fees BUILIDNG
ANCHK Plan Check Fee BUILIDNG
Business License BUILIDNG
IMF