04100155 CITY OF CUPERTINO F" "< ''• `� s�%'�"' `�"�"'`�"�' "'
BUILDING DIVISION PERMIT VAC 0NTRACTORANFORMAT>ION
BUILDING ADDRESS: PERMIT NO.
A PERFECT CLIMATE 04100155
OWNER' AME:-W 13STAPT-GS BR PERMIT ISSUE DATE
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ONE: SANITARY �fttOL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION non
U I Iemby rd' Nal 1 am Iic.d un&r gra mom or Clmpmr 9(mmmcncing s LED
with Semion JOtlll)of Division Sof We Bu4nrsand Professions Cade.and my licenm is Il't�a't�Lro,
s in foil fora and cff
WE LiccnmClss Lic.N REPLACE FURNACE
n�p� Dau: Comment,
11 7
A CrallW SDECL/s ION NnV �s 2004
I underwnJ mY plana shall be umJ u Puhlic records
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G Liecnmd Pnafetionel
3 OWNER-BUILDER DECLARATION A Q O ®� if
I I berth'uff,m Nal 1 am exempt from the Commences License Law for the k%pL99pf Ipy4m IIII
o O following mason.(Section J(Y31.5,Busines and Professinm Code:Any city or money
K$ which myuims a permit m construct,alma improve,demolish,m repair any awnum
w—'^ prior to its issuance.also requires lM applicant for such permit to Me a Signed statement
Rol he isliceuelpursuant toNeprovisions ofNeConuactor'sLicenselaw(Chtie,9 Sq. Ft. Floor Area Vanua[
FFG (commencing with Section 7(l10)of Division 3 of the Business and Professions Cone)or
i $
that he is eumpt therefrom and the buns fm We alleged exampuon.Any violation of
Section 7031.5 by airy Fi liom for a permit subjects We riPPlkaat re a civil penalty of 3 MN er0 0 Occupancy Type
not mom Wm fie hundred dollars($500).
1,u owner of the property,w my employees with wages as Weir sole compensation.
will do Be work,and the s4uaum is not intended or offered for sale(Sec.70,14,Business
and Professions Codac
e:The Contractors t W s License Law does roapply an owner of Required Inspections
progenywho WiIdsor improves thereon,endwht doessuch work himselforthrough his
owncmployees,provided Nat such imptosumenu she not intended oroRered fofsda.If,
hmwe ,We building or improvement is sold within one year ofcompletion.the owner.
Wilda will have the burden of proving Na M did not build or improve for purpose of
ask.).
❑1,as owner of the property,am exclusively contmming with Iiccnsed co mucters to
construct the project(Sec.70Cd.Burimea and Profusions Code:)The Convectors Li-
cense Law doer not apply to an owner of property who builds or improves Nemon,and
who contracts for Such projects with a eonmctoc s)licensed pursuant to the Commences
Lk:eme law.
❑l am exempt under ga. ,B A P C for Ws Tenon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penshy of perjury one of We following declarations: -
1 marc and will mainmin a Cenifcate of C.rom.I W self-insure for Worker's Compen-
auon,u provided for by Section 3700 of We Labor Code,for We pCormmance of the
work far which Nis permit is issued.
1 have and will maimmn Worker Compensation Insunnec,as motored by Section
37 of the labor Cade,far We performance of the work for which this pencil is issued.
My Workces Co pens ion lnsu mance offer and Policy n y ^� a
Came,: Pali,No.: O
CERTI KATE OF EJ PEON FROM 0 S'
COMPENSATION INSURANCE ,
(Thumction need not W completed Rde permit is form=hundred dollms($100)
or less.)
I certify Wa in the performance of the work for which this Permit is issued,l shell not
employ any person in any mamncrso as to become subject to the Workers'Compensation
Lawa of California.Be
Applicant
NOTICE TO APPLICANT:IL arm,making this ce.ificare or Exemption,you should
become subject to We Worker's CmnN=don pmvisions of We Lamer CMe.you most
.J O foMwith comply with such pmviau itor this Permit shall be deemed mmkcd.
Z
I hereby affirm that Were is a construction lending agency for the performance or
` CONSTRUCTION LENDING AGENCY
C'�: the work for which this permit is issued(Sec.3097,Co.C.)
VA Q Lender's Name
6. Lender's Andress
U C) 1 certify that I hors mad this application and sure Nat We slain information is
U.t-' correct.I agree to comply with all city and county ordinance and state laws mlating nc
0 V building construction.and hereby aummis MPRCSC mover or Nis City to enter upon the
r Ito above-rom uuned proPcrty for ins,scuon purposes.
F"
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Tap liabiliucs,judgments.Coats and experser which may in any way see=against mid City
V;— APPLIC ucneeUr We DERSTANDS AOf Il Permit.
N WILL MP WITH ALL NON-PO Issued by: Date 6 --
OU G ATIONS. Q
Re-roofs
nmumo A IicanUCom er GaleHAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building occupant moa or handle hevudous material
acnned by Ne Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ode,Section 25512(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya �jNuWin Nc a locant or fuwm bmlain t tee a amt m devien wmmh If a roof is installed without first obtaining an inspection,I agree to remove
PP gby Wen aAirmit hazardous air conlaminanas u dcfnca by Nc Bay Arta Air Quality Managcmcm all new materials for inspection.
iatriaJ
❑Yca
I have rtW Netuaamnusmaprials rcquimmm�ts under Chapurai95 of rhe Glifnry
niafM Ma SmetyCodc,Seeuou255o5,25533andM53a.lundcrsta wif We Wilding
Doerfi
nll haxc a en l Nnl it' Y rtiponsibilitY nc mufY Inc oavpenl of N
mornoil me prig an�. faatifemeora �j Signature of Applicant Date
4ieedasenl �c nc All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY Of Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: h PERMIT # 6 q I M 1 CJs
OWNER'S NAME: - PHONE # Q - —
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: _yT
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical012
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
� b
Owner/Contractor Signature Date
CITY OF CUPERTINO
UPE
_ RTINO PERMIT APPLICATION FORM
'"FAM /^ j� /1 Date:
Building Address: LJ
Owner's Name: Phope #:
Contractor: one: C( 3- F&I License #:
Contact: Phone: V aa U Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential 2' Commercial ❑
For Residential Installations:
Attic E] I" floor C3 2°d floor ❑
Adhere to min set back requirement[]
,or Commercial Installations:
eplacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calcul ns re�ire r new installation ❑
New installatio Planning Approval uired ❑
Cost of Proj et: T e of Construction: ! Occupancy group:
(�
Strapped On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty�if
A hcable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
1 BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
-"\BREMRECEPT 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
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