04060149 CITY OF CUPEWfINO
BUILDING DIVISION PERMIT ,CONTRACTOR INFORMATION�-�.,'.
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BUILDING ADDRESS: A B S HEATING & AIR COND PERMIT"°04060149
7625 ERIN WY
OWNER'S NAME: PERMITI SUEDATE
JOSEPH LEE 334 SHAMROCK NE: SANITARY NO. CONTROL NO.
(408) 238-7178
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
yO Z LICENSED CONTRACTOR'S DECLARATION ng Job Description
Z5 p
m C eM¢6yaffirm NuIamfthe Bo underprevisionsof Cook.and
my licermu
qU wiNSecionlgllpofDivi4an]ofNeeusir¢vandRofessioruCode.andmylicevcu !n� I�
z a<<IlfZ IcIT '. �L� g (y' rb?U REPLACE FURNACE & ADD A/C FONA EF0
"=p Dam Cm,Ktd\ ARCHITECTS DEC RpU TI N JUN 24 2004
>v Curxnd my plans shall M usd o puMiFrtrnfds
JyU
3 Licensed Pmfnabonal
spy OWNER-BUILDER DECLARATION Bi U N
1 hereby affirm on 1 am exempt from me Contractors :Any c Law for the sed ILDIo�'
po following.Imran.(Section I,?0 outs Business and ,derions CWC:Any cityorcounty
m which its isu a e.alm re cnnswd alteq improve,demolish,or opsin ed twctme
prior c,its issuance.also requires toe:ted visions of for such permit w Glc a signed summcm
,.a mashe is Ging.)porction7 )of Division
of oW Comucrosand Prselaw(Chapiv9 Sq.Ft. Floor Area Valuation
��� (commencixempth Section7") basis for
of alleged
Professions Cadic)Mon or
i 5$ that W u exempt therefrom and the Emu far the alleged exempton.Any violation of
Section 7031.3 by any applicant for a Permit arbiters on,applicant in a civil penally of aro 0 . Occupancy Type
not mom than Eve hundred dollars(5500).
❑1,as owner of the property.or my employees with wages u the'v sole camptnx ion,
will do dam work and me structure is not intended or offered for sale(Sex.7044,Business
and Professinm Code:The Contractor,U..Law does ant apply to an owt¢r of Required Inspections
property who Wild,ortmpoins themon,and whodoessuch work himselformough his
own employees.provided mat such improvements are not intended oro02red for sale.IL
however,the building or improvement is sold within one you of complcuon,he owner.
builder will ban the burden of Moving that he did not Wild or improve for porpom of
sale.).
T,u owner of the property.am exclusively contracting with licensed contractors to
consumer on,Maect(Sec.7144,Business and Professions Codc:)The Conuactari Li
cense taw does not apply to an owner of property who Wilds or improves Merton,and
who contracts for such projects with a contractor(s)licensed pursuant o me Convectors
License Law.
❑1 on,exempt under Sec. ,B A P C for Nu remon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby moi under penalty of perjury one of the following declarations:
1 bans and will maintain a Ccrufmam of Consent to self-insure for Worker'sCompco-
satim,as provided for by Section 37W of the Labor Code.for me performance of the
we" for which this permit is issued. _
❑1 have and will maintain Workers Comptnsnion Iruurance,as rtgrired by Section
1700 of me Labor Code,for me peiformanee of the work For which this pmmit is issued.
My Wor 's Co pematioo Insurance tarsen and PolicygB�W�n
cmfier. CERTIFICATE Policy No.:I�a�SI IIOL J"'p
OF :EMPr10N FR0lQW11RJ'.ERS'
COMPENSATION INSUR
fir icametion need not he mmpkted if the permit is forme,hundred dollars(Slml)
or less.)
1 certify that in to performance of the work for which this permit u issucL I shall not
employ any person in my manner an of to become subject to NC Workcr5''Compcmation
Laws of California.Date
Applicant
NOTICE TO APPUCANT:If,after making this Certificate of Exemption,you should
become$Object to the Worker'a Com formation provisions of the Labor Code,you must
.JZ forthwith comply with such provisions or this permit shall W deemed invoked.
Z O CONSTRUCTION LENDING AGENCY
(-+ 1hemhyaffirm that mere iso crmuuctinn lendingagenry for ted perrormmtx of
fY. r1 me work for which mu permit is issued(Sec.3097,Civ.C.)
Qtender's Name
7 z Lcntler's Address
U C I mnify mat 1 tine read his application and sur that the above infmmnim is
(s. t•-' correct-I agree to comply with all city and county ordinances and sum laws relating to
0U Wilding commuction.and hereby authome mprucmutvu of this city to con option me
W morn,mentioned popery for inspection purposes.
4. (We)egme to save,indemnify and keep harmless the,City of Cupertino against
ti
liabilities,judgments,costs and expenses which may in my way accmc against mid City
Of me
U Z APPL C9ANTeUNDERSTANDStarting of this pernot.
AND WILL COMPLY WITH ALL NON-POINT Issued by: Da
SOURC RE ATIONS. (� �/
I 4 Re-roofs
Signature of ApplicanAZARD or Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant in future Wilding occupant store or handle hazardous material
m defined by dte Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
0Yes Nr
wdl be apn0txns ter rrmre Wmm�g actrvmt r,e egmpment nr div+=ea whmh If a roof is installed without first obtaining an inspection,I agree to remove
mit ha'rardnus air cmnuminanu m dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
District?
UYcs [a Nr
I have mad me hasardnus materials requirements under Chapmr6.95 of me Califon
ria Healu A Safety Code.Sectors 25515,M533 and 25534.1 undeuded thoifine Wilding
does not emrenty base a tenant Out it is my responsibility m madly the occupant of me
myui cans hit mum W met prior m issuance of a CcrtiOcam of Occupancy. Signature of Applicant Date
V 0All roof coverings to be Class"B"or better
Per M mmmned ag.t m
Community Development
k j' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
a CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: r ^ PERMIT #
�Y i1 I.v
OWNER'S NAME: J PHONE # �J3
GENERAL CONTRACTOR: y4,/3. C FAX # LIT
(-�
I am not using any subcontractors: U-I /
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
athingMasonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
VL i Tile i
-off
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
SPERTiNO PERMIT APPLICATION FORM
APN # D / C� Date: / Q4
Building Address:
Owner's Name: C G S� Phone#: r ^'
Phone: License
:
ContractorG, I iI � /)
J.flex i2 W�.i�TlOtlr 1��0
Contact: Phone: Cupertino Business License#:
9,4 , A
Building Permit Info:
Bldg ❑ Elect Q� Plumb ❑ Mech
Job Description:
C(--' OJ o -
Residential Commercial ❑
For Residential Installations:
Attic ❑ 151 floor El 2nd floor F1dhere to min set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Proj t:��� Type of Construction: Occupan ulf
JAV AC
Strapped LJ On Platform LJonded ElSq.Ft. Flo
New Location ElReplacement ❑
Qty. if
A i able Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMEURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMARU4AN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNGTT
EPERMFEE 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 /S ` BUILDING