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04110159CITY OF CUPERTINO BUILDING DIVISION PERNHT CONTRACTOR INFORMATION "LDING ADDRESS: A &MH HEATING PERMIT No 04110159 22266 N DE ANZA CL OWNER'S NAME: PERMrf ISSUE DATE STEVE DERMAN 770 CHESTNUT ST 4 ZONE: SANITARY NO. CONTROL N0. (408)279-0722 ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECTPN PLUMB MECH _. = / LICENSEDCONIRd /`` lob Descrlp uncle provisions of 9 (commencing 1 thereby affirm Net I am under previsions �� sC.d., 7W0)af Division ]of NC Busincssrerd$pfeuinns Code, end my license is wiOsS fffi. Business - f6ra, _ -kms - REPLACE FURNACE ,Xseneanaerf. Llcenu 1 , Dak-- - _ _ _ _ _ DEC ARCH S DEC - ll 'tu W as '2'/ / ZO 0� utorcand my plans shall used puhlic M.Rus Liccnud OWNER -BUILDER DECLARATION urachyprofessaffir License Law for the I Wraso affirm Nat 1 exempt from Inc Contrhis Ca c county fallowing reason. (Section RDstr Business and ons Cade: Any city 1. are. & s to improv,h or repair anytatement �gp/ - --- poor toitsisunpermit ct. also aiports the,pplic Permit statement me the applicant for sucComnermiuoccuse priorroitscensedpursuant F[. Floor Area - — - _ - Valuation be to Law - Sq. (that commiafianudpumnmmth)ofDivion.a oftheStrxmhlurnsesaw(Chapror9 (commencing with Section 7000) of Divinion3 of @c Business and Professions Cadc)ur - "—"-" — - --- -' -------' - '--' Nn he is eumpt thcrt(rom and the basis for the alleged Gumption. Any violation of � oro 0 Occupancy Type Section 7031.5 by any applicant for a permit subjects me applicant to a civil penally of not mom than Eve hundred dollars ($5130). I,azow afthepropwy,ormyemployeaswiNwaguutneirwkcomp codon, Required Inspections will da the work. and life atwcture is not intendedarolfered fmule(Sec. 7001, Business and Professions Codc: The Commuctors License Law does nal apply to an owner of q p pmpeny who builds or imparms thereon, and who doss such work himwlf or through his own employe¢, provided thld such improvements are nor intended oroRered for sale. IL however; the building or impmvemem is said within one year of complcuon, Ne owner, builder will have the hurden of proving that he did not build or improve for purpose of Sale.). ❑ 1. as owner of the propcny, am excludvely contracting with licensed contractors to construct Ne project (Sec. 7006, Business and Professions Code) The Contrulni s Li. - ceme, law docs not apply to in owner of pmpeny who Guilds or improves themon, and who Contracts for such projects with a contractors, licensed pursuant to the Convector's - License Law, ❑ I am exempt under Sea ,B&P C far this seawn Crw Data WORKER'S COMPENSATION DECLARATION 1 hereby arm under penalty of perjury one of Use following declarations: I naw and will maintain a CCNBeate of Consent to self -insure for Worker'sCompen- smion, as provided for by Section 37W of the labor Codc, for me performance of the work for which this permit is issued. - - '- I haw and will maintain Worker's Com asm auoo Insurance, as required by Section ' 37W of Ne labor Coale, for the performance of the work ff s.which this permit is issued. My Workers Compensation Inwnrrtt arricr and_Por, .bpf am: CamPolic R FlC TE OF 7FM FR 'WORKERS' COMPENSATION INSUR NCE (Tru section reed not W complcu d irthe Permit is IOronc hundreddollso ($101)) ar lux) I cerufv that in 0. Performance of me work for which this Permit is issued. I snail at employ any pawn in any mannerw as les become subject to on, Workers Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: IL after making this Ccnifin¢ of Eacmpion, you should become subject in me Worker's Calumniation previsions or the feWr Code. you must „ forthwith comply with such provisions or this Permit small W deemed revoked. LENDING AGENCY OldCONSTRUCTION len ding agency far lot perfurtnanw of 1horW a1Bthi marmess issued( ecr3 ' me work for which this permit is issued (Sec. 7041, Co. C.) lrnders Nam. I,anticrs Add. 1 tarty that 1 have read mil application and lute lost the above in formaiun is ' mrrect I agree W comply wire all city and county on inane t and sate laws relating to above-gcoimned Construction, and Wait, ma,ccuon urepnsenurivcv of this cirymenxr upon me above -(We) gree opertyUs findmnify a lue,hs (We) agree m cove, indemnify end heap harmless the Circ n Cupenst s against j they in any way accnc against said City / I 1 AeonxquNT of the granting ar this perm it. inconsequent ofthecostsand of this Permit. ' 'APPLICANT UNDERSTANDS AND ILL COMPLY WITH A NON -POINT Issued by: Date SOURCLATIONS. Re -roofs Type of Roof nature Of Applicant omuaclorDau HAZARDOUS MATERIAL ISCLOSURE Will me applicant or future building occupant store or handle hvardous maedal as defined by the Cupenino Municipal Code, Chapter 9.12. and rise Health and Safety code. Section 25532m)7All roofs shall be inspected prior to any roofing material being installed. ❑ Yu u If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or fmum building Occupant use equipment or devices which emit harar0ous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Ycs I hats orad the hvardous materials requirements under Chapter 6.95 of the Califon ria Health& Safety Codc, Sccuont 25505.25577 and 2iSM0 l understand that irthe Wilding J no currently hart a cream that it u my resprmibiliry m m ul'y the ..'art of the an eofaCCmfic uof mm whicnmug'bet inpa? Signature of Applicant Date AI I roof coverings to be Class "B" or better Owner or authorized agent Dat. "umna" CITY OF PEkTINO CITY OF CUPERTINO FURNACE/AC PERMIT APPLICATION FORM e�j-1 l els APN #3 s/ -®4 � D I -/ Date: —2- . Building Address: . as 6 D15 �WM REMFURN Owner's Name: -r-F—(` Phone #:, f83 4 Y7-)- Contra t Q� r Phone: n3 J 7� G G �f License Contact: Phone: b>4c,� Pr+Ec�.s 79- OZ,_ Cupertino Business License #: Building Permit Info: MECHANICAL Bldg ❑ Elect ❑ Plumb ❑ Mech Lam' ELECTRICAL BSEISMICRE Job Description: . Residential Commercial. ❑ Seismic Commercial For Residential Installations: ❑ Is` floor ❑ 2nd floor ❑ EPERMITFEE Attic ELECTRICAL dhere to min set back requirement ❑ Mech Permit Issuance MECHANICAL PPERMITFEE or Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ PLUMBING Structural Calculations required for new installation Bldg Permit Fees New installation Planning AnDroval Re wired ❑ BPLANCHK Cost of Project Type of Construction: Occupancy group: Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: New Location ❑ Replacement ❑ Qty -if r,•__L,) Uee m FPP T)Pcrrinfinn Fee Group t uvau,v— BENERGY Energy BUILDING REMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit > 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BRENIRECEPT 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 BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING