04100142 CITY 0T CUPE RTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION '
BU I LDING ADDRESS: ABC COOLING IS, HEATING PERMIT N04100142
-sL188 ELMSFORD DR
OWNER'S NAME: PERMIT ISSUE DATE
PHILLIP LELLMAN 31845 HAYMAN ST. 10/20/2004
]ONE: SANITARY N0, CONTROL NO.
(510) 471-8181
ARCH TEC1ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0, LICENSED CONTRACTOR'S DECLARATION lob Description
=�G 1 hereby affirm that 1 am licensed under provisions or Chapter 9(commencing p
With Section 7008)of Division 3 of the Business and professions Code,and my license is
inlull fl, de �d 3T�13 REPLACE FURNACE & ADD A/C
Dt27= Liccne Lie
z r w Dalc C ram,
4Y=o, ARCHI 0
Y C< I unde¢mnJ my plans shall used as Public rccnNa
JyU
3 N Licensed Pmfcsxinwl
i0
v, OWNER BUILDER DECLARATION
L 1 hereby affirm that I am exempt from me Contractor's License law for the
O O following reason.(Section 7031.3,Business and Professions Code;Any city nr Onunty
K w which requires a permit to construct,after.Improve.demolish,m repair any structure 9111
,a Prior In its issuance, Is.requims the applicant for such permit to file a signed statement
that he is licensed pursuant o the pmvisintu of the Comracmr's Liccnac Law(Chapter 9 Sq.Ft. Floor Area Valuation
.at i-a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
n; that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7831.5 by any applicant for a permit subjects the applicant 10 a civil Penally of 36AWAWrbe Occupancy Type
not more than low,hundred dollars(3508).
0 1,a owner of the property,or my employees with wages as their sole compensation,
will do the work,and the strucmm is not intended or offered for sale(Sec.7044,Business
and Pmfcssions Code:The enormous's License Law dues not apply to an owner or Required Inspections
Own
property whoaye builds or improves th hapf vander who does such work himsslred for ugh his
ownemplorebuiprovided p suchimprovementsin net ear of
or mtreat.far Sale.own It,
however.the building or den of proving
is sold within one year of completion.one me,or
builticr will have the burden of proving Nal he did not hot III or improve for puTose of
sale.).
0 1,as Owner of the property,am exclusively concocting with licensed contractors to f
construct the Former(Sec.70,44.Business and Professions Code:)The Contractors Li. /
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to Ne Contractors V� ,
License La-
0 I am exempt under Sec. B&P C for this reason
Owner Dam V
WORKER'S COMPENSATION DECLARATION
I hereby sprint under penally of perjury one Of the following declarations: -
0 I have and will maintain a Certificate of Consem m self-inrvm for Worker's Cum,pe,
satiun,as provided for by Section 37M of the labor Cntle,for Ne performance of the
Werk for which this Permit is Iswed.
W.
and will maintain Worker's Compensation Insurance,az required by Section
TOo of the Labor Code,for the performance of the work for which this permit is issued.
My Wmrkcr's` - lis% Srn dPolicy nuya
.,
'S 10
Carter� y Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not he comPleted if the permit is for one hundred dollars IS[fit))
or loss.)
I econ(v Nat in the performance Of the work for which this Permit is{scored.1 shall not
employ any pera any manner en a m hccume subject to the Workers Compensation
Laws Of California!Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become&Object to the Workers Compensation Provisions of the Lahnr Code,you must
., rZ forthwith comply with such provisions or this Permit shall Na deemed revoked.
zCONSTRUCTION LENDING AGENCY
1 thereby affirm that then is a emrswction lending agency rnr the performance of
5 the work or which this permit]s issued(Sec.3091.Civ.C.)
W Lender's Name
�• Landar's Address
Z
U 1 cenify that l bac read this application and state that to,above inforreatiun is
D, E-• correct,I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representaovice Of this city to enter upon the
r a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Fh Iiabllitia,judgments.costs and expenses which may in any way accrue against said City
C.) z mennsequcncco he gam in of tIn
t. s
^ APPLICANT DEBST WILL C PLY WITH ALL N POINT Issued
.by: Datc
SOUR %��
°Y Re-roofs
/O
Signawm of APPIiwte
HAZ,ARDO De
t]A RDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant fulumbuilJinguccupamsmrc or handle hasardous material
a defined by the COpenin Municipal COJc,CAapmr 9.13,and the Health and Safety
Cotte,Section]5532(a)? All roofs shall be inspected prior to any roofing material being installed.
puts u
wits to.aPPlipam ""Nofabim wilding xcupam tau cyuipmcm or Jcviccs which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmardous air omen nu a defined by the Bay Area Air Quality Management all new materials for inspection.
Distrix?
❑Yes
No
I have mad Nc h'a'ms materials requirements under Chaptcril.95 of the Califon
Iia Health.&Safcty Cak.Scadasv 25515.15533 and]5534.1 undxstaml thaif the building
Jars no.,curendy ac a tenant that i an res, Tility m notify the <u ant of our
redone mtsw mOSre P' I s<usuce CcnifimeOfOccvpan Signature of Applicant Date
Owncruauthmiapd agent All roof coverings to be Class "B" or better
Doc
CITY OF CUPERTINO
«- FURNACE/AC o
OF
CUPERTINO PERMIT APPLICATION FORM
APN # 7 ,5' Z U 7 a -
Building Address://
Owner's Name: /_0 p Q- �o bJ Phone#:
Contractor: /j /,OPhone: License 3 �.2 3 $3
�/ /w5 S!o �/ 7/-
Contact: �/ � Phone:5/o y / _ VC/ Cupertino Business License#:
1
Building Pemrit Info:
Bldg ❑ Elect Plumb Mech
Jo esc •ption:
Residential 1WCommercial ❑
For Residential Installations:
Attic ❑ I'` floor ❑ 2nd floor❑
® Adhere to min set back requirement( 4
For Commercial Installations:
Replacem t a e weight Q dditional weight(structural calcs) ❑
Struct Calculations requiredfo new installation ElNew nstallation PlanningA rov 1 Re uired ❑
Co t of Project: Type of Construe io - Occupanc gro
`�/// . [TD
Stra ed LJ-.on Platfo ❑ Bonded LJ Sq.Ft. Flo Area:
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
/ I 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
/ PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING