03110141 CITY OF CUPEWI'INO
BUILDINGDIVISION PERMIT CON'IRACTORINFORMATION £
BUILDING ADDRESS: AAA FURNACE & AIR CONDITIO TM&NO03110141
OWNER'S NAME: PERMIT ISSUE DATE
003
NE: SANITARY NO. CONTROL NO.
(408) 293-4717
ARCHITLCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
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LICENSEDCONTRACTORS
and.,provisions
of CON Job Description
C I hereby aff rte that 1 am licensed under provisions of Chapter Y(cnmmcn[ing P
U with Scctiun l(Mltpnf DivixmnJor Jtc Business and Prnfcsxinns Codc.and myliccnsc is
R in full force and e
iq_ u[ense Isoe - COLO Llc.a ). CHANGE FURNACE & ADD A/C
Dam Contractor (g�7
ARCI{ITECTS GC 69 O r FOGDApa>_.�®
f U 1 understand my plans shall he used as public records
e u. Licensed Pmfessmwl a
OS OWNER BUILDER DECLARATION APR L 2004
y i S 1 hereby affirm that I am exempt from the Comaaors License Law for the
-O O following mason.(Section 7101.5.Business and Professions Cale:Any city os county
m which mquires a permit to construct,alter,improve,demolish,or repair any structure figx!� S7000
prionoux issuance.also requires the applicant forsuch permit a file a signed statement
-[ that he is licensed pursuant the provisions of the Contractor's License law(Chapter 9 Sq. Ft. Floor Area IUat10❑ -
iF0 (commencing with Section 7000)ofDivision 3 of the 8 usibeac and Professions Cook)or
i $
that he is exempt Ncrefrom And the para for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the Applicant a civil ritually of 3 @XN(l,1Mcr0 0 Occupancy Type
not m.m Bonn five hundred dollars(SSW). P Y YP
❑1,as owner of the property,or my employees with wages u their Sold compensation,
will do Ne work,and the avumum is not intended or offered for sale(Sec.7044,Business
and Pmfmiorts Codc:The Commetoh License law does not apply to an owner of Required Inspections
property who builds or improw,thereon,and who does such work himself.,through his
Own employees,provided that improvements arc not intended.,offered for sale.If,
however,the building or improvement is Sold within one year of eamide ion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
Side.).
❑1,as owner or the property,a exclusively comnainis with licensed eoutnebrs to
constrect the project(Sec.7044,Business and Professions Code:)The C.ObaetOrf Li-
cense Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a contractors)licensed pursuant to the Conuanor's
License Law.
Q 1 am exempt under Sec. .B&P C for Nis moon
Own Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
I have and will maintain a Cerufinte of Conant a wlbinsure for WorkersCompcn-
satian,as provided for by Section 37W of the La Wr Code,for the pedmmaMe of the
work for which Nis permit is issued.
1 ban and will maintain Worker's Compensation insurance,as required by Section
W of the LAW,Code,far the performance of Ne weak for which Nis permit is issued.
My Workers Compenssanation uando Ga mice and Policy number aa: 41 �r�
Caari[C 'C Policy No..
' RTIFI ATE FEXEMPTIONFRO WORKERS'
COMPENSATION INSURANCE
Mis section need not be completed if the permit Is for one hundred dollars(Sip))
a less.)
I certify Not in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to homme subject to the Workers'Compensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,after making this Celli Beate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
O fonhwith comply with such provisions or this perm it that he deemed revoked.
z CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a construction lending agency for the Performance of
0: Be work for which this pmmit is issued(Sec.309],Civ.C.1
Lender's Name
31 Lender's Address
::) z
U O I Certify that 1 have read this application and sate that Nc shove information is
U. F., eorteei l agree to comply with all city and county ordinances and state laws relating to
C)V Wilding construetion,and hereby gindamim rcpresermiives of this city to enter upon the
rW ahovc(We) ned area to rerlysave rotinspectionan keep ha
gy
(We)agree to save,indemnify and kith harmless the City of =gamins againstBab /t
UZ in
of ts.the costs granand of this expenses which may in anyway accrvc against said City
U Z A cPLICANTc of UNDERSTANDS
of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaDO m
Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant or future building occupant sore or handle M1rramaredal
as defined by the Cupertino Municipal Codc.Chapter 9.12.and the HcaiO IN anand Safety
Code,Section 25533(ap All roofs shall be inspected prior to an roofing material beim
El Yes ❑Na P P Y g g installed.
Will the applicant or future building occupant use equipment Or device$which If a roof is installed without first obtaining an inspection,I agree to remove
it havardmus air contaminants as defined by Be Bay Area Air Quality Management all new materials for inspection.
7District?
❑Ycs ON.
I have mad the heran nus materials requirements under Chapmf 6.95 of the Califor
Health At Safety Caic.Seeuwo 25515,2553]and 15534.1 understand Na iftM Wilding .
es not Commit,have a reran.Nat it;s my respmuibility a notify the aropan,of the
/iy��cnu which muu et poor tet issuance ora certificate or aeapamey. Signature of Applicant Date
`�'-- � All roof coverings to be Class "B" or better
wner or atumn d agent pate
CITY OF CUPERTINO
�o FURNACE/AC 3��
CUPEkTiNO PERMIT APPLICATION FORM
APN# 02 , Z® — Q /9 Date:
Building Address: IdOf 7 4
Owner's Name: Phone#:
Contractor: License#:
Contact: Cupertino Business License#:
Building Permit'.Info:
Bldg ❑ Elect xr Plumb ❑ Mech
Job Description:
v
Residential [� Commercial ❑ Exfc,�.✓ 7 cyst uc�f
For Residential Installations:
® Attic ❑ ls` floor ❑ 2"a floor El
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
trapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. ilf-
ApplieaWe 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
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMTI FEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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