05080272 CITY OF CUPERTINO raxr ` —
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION,
BUILDING ADDRESS: A & H HEATING PERMIT NO.05080272
OWNER'SNAME: PERMIT ISSUE DATE
MICHAEL ICADE
NE:
SANITARY NO. CONTROL NO.
(408) 279-0722
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
°00 LICENSED CONTRACTOR'S DECLARATION - lob Description
Z C 1 hereby affirm the,1 am licensed under prnvisions or Chapter 9(commencing p
<U
with Section 7")of Division 3 of NC Business and Professions Code,and my license is
o Lint nesa((r« REPLACE FURNACE & ADD A/C
_M2 Licemc Class tJ—Zb --Lk.n
o�p Dam ComracCL ��
gipp, - ARCHITECTSDartal ICs
C-s -1 understand my pians shell be used as public meard�
yU
3Q� Licensed Professional
OWNER-BUILDER DECLARATION
<S 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
m which acquires a permit to construct.slot,improve,demolish,or repair any structure _ e, n //=O. $G600
poor to as ISNNCe,also meal s the applicant for such permit to file a Signed slaNmcm tttggq
Jut he is licensed pursuant to the pmvisiom of to Comment's license LOA,(Chapter 9 Sq.Ft. Floor Area Il rtt� I�I L)flX Valuation
pFC (commencing with Section 7")or Division)of the Business and Professions Code)or 1�7e1Yy `41�
y that he is exempt therefrom and the basin for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects he applicanfto a civil penalty of r Occupancy Type
not more than five hundred dollar($500).
0 1,as owner ofthe pmpart,army employees with wages as their sole compensation,
will de,em work.and the swcnre is not intended or offered par sale(Sec.7066.Business
and Professions Code:The contractor's License Law does not apply n an owner of Required Inspections
property who builds or improves memon,and who docs such work himself or through his
own employ=,provided mat such improvements arc not intended or offered for sale.If,
however,me building or improvement is said within one year of compiled..,the owner-
builder will have the burden of proving that he did Out Wild or improve for purpose of
sato.).
0 1,a owner of the property,am exclusively contracting with licensed emomm o x to
construct me project(Sec.7066,Business and Procausions Code:)The Contractor's Li.
cense law does not apply As an owner.f property who Wilds or improves memon,and
who contracts for such projects with a eomnemr(s)licensed Pursuant o the Canlracnf 3
License La
rl lamesemptimlar See. ,B&PCfathiaremrn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby salmon under Penalty of perjury one of to following declarations:
1 hen and will maintain a CoNBcate of Carmelo to self-insum ror Worker's Compcm
7371,01)
ior,v pmvidrd fm by Section 37W of the Labor Code,for the pertarnan m of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,m myuired by Section
of he LAW,Code,for lW performance of the work for which suis permit is issued.
y Wmkera Campmeabin hours.aria and Polity nunitar,rter. f�L/,L /tr%�5 PolityNo.:eYl9'l��
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section raced not be completed if tbe permit is forone Wndnd dollars($100)
ar less.) ,
1 certify than in the performance of to work for which this permit is iwucd,I shall not
employ any person in any manner so as At become subject to me Workers'Compensation
Laws of California.Data
Applinm
NOTICE TO APPLICANT:If,after making this Ccnificare of Exemption,you should
become subject an the Workers Compensation provisions of the Labor Crude,you must
.J z forthwith comply with such provisions or this permit shall be deemed invoked.
Z O CONSTRUCTION LENDING AGENCY
{+� l hereby affirm mm inert is a emwruction lending agency lot me performance of
Rai me work for which his permit u issued(Sec.3099,Civ.C)
W Q Isndcis Name-
z Lender's Address '
L) 1 comfy that 1 have rad this application and show mat she aWve i.f.m.tiun is
cormea.1 agree to comply with all city and county ordinanms and stale laws misting no
V building construction.and hereby authorim repwsenmives of this city to enter upon the
W above-mentioned profanity far impaction purposes.
,n gy (We-)agree to save,indemnify and keep humless the City of Cupernino against
fA liabilidmajudgmenu.cosu andexpcnses which may in anyway see=agaMtanid City
C)z IMIL
APPIL,ICANT UNDERSTANDS AtND mWILL COMPLY WITH ALL NON-POINT Issued by: Date �- e
SOURCE GULATIONS.
a /� -3ff7S Re-roofs
Sigmamrc pmann
eComcs.r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tM applicant or future Wilding Occupant store or handle hazardous material
Cu dented by the Cupenino Municipal Code.Chapter 9.13.and the Hcalm and Safety
❑Yrs
Cole.Section 25532(6)? N. All roofs shall be inspected prior to any roofing material being installed.
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 hasardous air contaminants AS defined by the Bay Area Air Quality Management all new materials for inspection.
7d..
stria?
0 Yes W___
1 haveteat Nem cuus 25505,25533mde 5under&m= 6aLifhe Wilding
no(staSafety Cede,Sectiom 755(15,355JJ and255J4.1 undcrsmnd thatif Jac Willing
mol curaviremcnu whmuslWmtpnormiss ce.r1CenlOaa1a.fOce.paney. Signature of Applicant Date
authori'rc0 agent � Data�5 All roof coverings to be Class "B"or better
Owner tar
.m., Community Development
10300 Torre Avenue
i% ✓
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRE S: PERMIT #
ZZZS�c (�tzre fb��2?Z
OWNER'S NAME: PHONE #1/O 8' Z 7'� -07
GENERAL CONTRACTOR: T FAX # tZOF Z 7 (O l7
I am not using any subcontractors:
Signature Date
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
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
CITY OF CUPERTINO
FURNACE /AC �a 2,7 2--
iry r
..'.EI. TINO PERMIT APPLICATION FORM O
APN #; -- Date: ,
Buildimu Address: _ -
Owner's Name: � � Phone #:
Conu actor License #:
1'. Contact: - Phone #: --- -
1 ; DALPf
(.` Applicant/Contractor:
Building Perntit Info:
I'lumb" ec
t' 'Joli Description: (� hEtS - O(�u _ �— ---
,Residential: Z
t��G� ZZc�c�OG-(�t�LLeIICommercial:
'
Sq Ft Floor Area: $/Sq.Ft.: ---
,,< :ArclutectlEn ureer:� Valuation: �
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of Construction: Occupancy Group:
}...:' Qty. iP
A �licable Pee ID _ Fee Description Fee Gr011 _-
r,s BENERGY_ Energy BUILIDNG
BREMFURNRelocation of Furnace MEC1iA1!ICAL
BREMACOVER _ A/C Unit > 10,000 cfm MSCIIA�V'ICAL
BREMAIRHAN A/C Units <= 10, 000 cfm �YIECI IANICAL
BREMRECEPT Recptl, Switch & Outlets ELECTRICAL
' -1 BSEISMICRL ----- ----
Seismic Fcc Res BUILIDNG
1S EPERIVIITI-EE
Elec Permit Issuance ELECTRICAL. j
YIPERNIJTFEE Mech Permit Issuance MECHANICAL j
PPERMITFEI3 Plumbinmit Issue
-� - yu Per_ PLUMBING
BPERMFI=E BldpPerntit lees BUILIDNG
BPLANCHK - Plan Check Foe 1.3UILLDNG —�
BUS1.[C _ Business Liccnsc BUIL,IDNG
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