04100026 CITY OF CUPERTINO a � saa -�awr,t C: '* aaas.'eno- Fw n _
BUILDING DIVISION PERMIT. �CQNTRAt-1'QRjNF0RMATIQN :
BUILDING ADDRESS: PERMIT NO04100026 41(](](]2 6
10250 DE ANZ,& RIND
OWNER'S NAME:
PERMIT ISSUE DATE
WASHINGTON MUTUAL SANITARYNO. I CONTROL NO.
NE:
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
:Op LICENSED CONTRACTORS DECLARATION Job Description
i g wi I hereby affirm that I am Iiansed and mvisioo of Chapter 9(commencing
Scc on]BBB)of Diviaion]af NC Businev aadProfcuinns Cadc.and myliccnsc is
\/ 5-TON PACKAGE HVAC UNI
$Z License Claes �f .J O Lic.0 b JS $ ��°°
'moo Dam 1.7-5 Comracma fyv.c/a' CONTRACTOR: EMCOR /MESE MISE
'ta< 1 uARCHITECTS DECPON
rso my plans shall he uuJ as puN Won@
Ddu OCT 110 2004
3 o G LI=CmCd Professional
3 OWNER-BUI ERDy LARAMON
�r I hereby affirm that 1 am cxcm�m Ne Cmarac u's Lieenu paw for Plc
6E
p o following moon.(Section 703 1.5,Business and Professions Code:Any city or county IL
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which requires a permit m cnnsv«t,alar.improve,Jcmolixh,nr mpmr any structure J _ el
—i a, tt
prior to its issuance,also mquims the applicant for such permit to rite a signed statement _
< that he is licensed pursuanoNeprovisions orNeComnctor'sLictne,Law(Chei9 Sq. Ft.Floor Area Valua"' 797
sFC (commencing with Section 7")of Division 3 of the Business and Prefessiou Code)or �T-� .
'd $ that he is exempt therefrom and do huts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nut mom than RK hundred delta.(S500). 36941004 . 00
❑I.uowmr of Ne property,«my cmployces with wage as Nevi sole compcmadan,
will Us the work.and Neswnurt is not intended m errand far We(See7044,Bulinus
Required Inspections
and predications Code:The Comerman's License law doea nor apply m an owner or - - - - -
property who buildsor improves thereon,and who data such work himself or through his
Own employees,provided nor such improvements are not intended at oRered forsale.If.
however,the building or improvement is sold within one year of completion.One owner-
buildtr ,will ban the!roma of proving onus he did nos build or improve for purpose of
vile.). -
❑1.as owner of Ne property,am exclusively contracting with licensed co unmer ra m
construct the project(Sec.7044•Business and Professions Code:)The Contractor's Li.
cane law door not apply to an owner of property who builds or improvsa thereon,and
who convects for such projects with a conuacur(s)licensed pursuant o Ne Convacmts
Latent Law.
❑1 am exemia under Sec. B h P C for this moon
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pevhy of perjury one of the following drearau^ro:
1 hats and will maintain aCenificare of Consent m self-insure fm Worker's Compen- '
vision,u provided for by Section 3700 of the labor Code,for the performance of the
work for which this pewit is issued.
❑1 have and will maintain Worker's Compeuation Insurance,u rtyvirtd by Section
3]00 of the Labor Code.for the perfowaoce of Ne work for which this pewit is issued.
M loot's Compensation Insurance carrier and Policy number am:
ca Mu tr t,t,SA In C PolicyNo.: �3l01
CERTIFICATEOFEXEMPTIONFR RKERS'
COMPENSATION INSURANCE _ t
(This section need not mcompleted if the Permit is foram hundred dollars($Ia)
or less.)
1 certify our in the performance or the.,it for which this permit is issued.l Nall net
employ any person in any manrcr so as m become subject to One Workers Compeuauon -
Laws or California.D.
Applicant
NOTICE TO APPLICANT:If.spoor making this Certificate or Exemption,you SOME
become subject to to Worker's Compensation previsions of One labor Code,you must
.,2 foMwith comply with such provisions;or Nis permit shall be decreed revoked.
Z O CONSTRUCTION LENDING AGENCY
'T. I Acrthy affirm that Ncrc is a eonmmctinn lending agency for Nc Performance of
a the work for which Nis .it Is waved(Sec.3097,Civ.C.)
{4]Q U='s Nuns
G Lender's Address
U 0 1 certify that I bare mad this application and room has the shots information is .
Is. t•" Comet.1 agree to comply with all city and county on inences and sum laws mating N
0U building construction,and hereby authorim mpresenutivss of this city to came upon the
shove-mentioned property for inspecuon purposes.
Fn. (We)agree to...indemnify and keep harmless the City or Cupertino agaNst
N habilitiu,judgmcis.costs and expenses which may in any way acme against mid City
in
of the granting of
U?
APPLICANT eUNDERSTANDS AnND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S CE REGULATIONS.
c. /D �U-S=fes/ Re-roofs
Siloctursre of Applicand Dam
AZA OUSMATERIAISDISCLOSURE Type of Roof
Will thn applicant or future building Occupant store or handle ha rdous mammal
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
AMILCOde.Section 25s32eaY'
Yu �Nu All roofs shall be inspected prior to any roofing material being installed.
Wo1 rot app0cam tie stare building Occupant are eyainment pr tiers+=er whichIf a roof is installed without first obtaining an inspection,I agree to remove
I
zardous air contaminants az Jcfincd by the Bay Arca Air Quality Management all new materials for inspection.
] o^
❑YesI have mad the havaNnuS mamrialsmyuirt ens under Cheprer6.95 of Nc Califonlth aSafciyCade,Secuum25505,25533and25534.1and mwdthmifthc wilding
t cuncntly have a rental,Nat it is my mmonsitoduy to notify the occupant of Ne
mema which must be met pnorto iuuancc of a Cemficam of Occupancy. Signature Of Applicant Date
/L? -O�/ser auNorizcJ agent Date All roof coverings to be Class"B"or better
., Community Development
s 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
113 aI. SO :;. Oe C4117 n O 2(o
OWNER'S NAME: We \A:, ti \-V ti Vim. moo. PHONE # -70-) - '217 $ 25-3 v
GENERAL CONTRACTOR: FAX # cta - 5—/- G / SC
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/ acto ignature Date
CITY OF CUPERTINO
FURNACE/AC �
�UPERTINO PERMIT APPLICATION FORM
CZDate:
Eddress:JS.Szctcl „n S
Owner's Name: Phone #:
Contractor: Phone: License #:
5-/os6-7o 2o 6i/ :--115--
Contact:
--1/sContact: Phone: Cupertino Business License#:
A do 707 - 9'7,e 25-3 0
Building Permit InM:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description: 1 oAt s,js+� I11te fOr 1.Lk-e 5 Tov9,� u�
Residential ❑ Commercial �-
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor❑
Adhere to min set back requirement❑
or Commercial Igstallations-
Replace esame weight Additional weight (structural calcs) ❑
S ral Calculations requi d for new installation ❑
w installation Plannin A roval Re uired ❑
ost of Project: Type of Construction: / Occupan y gro
a ped ❑ n Platform ❑ Bonded ❑ Sq.Ft. Floor ea:
New Location ❑ Re lacemen
Qty. if
A li able Fee ID Fee Description Fee Group
/ BENERGY EnergyBUILDING
BRENUI RN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMATRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BLUEDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License 0 BUILDING
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