03060153 CITY OF CUPEWFINO X�, s
BUILDING DIVISION PERMTO
ITCONTRACR, INTORMATIO ...
BUILDING ADDRESS: UNITED AIR COMFORT PERMIT NO.O 3060153
OWNER'S NAME: 5819 N ANDREWS WAY PERMIT ISSUE DATE
NE (408) 771-8967 SANITARY NO. CONTROL NO.
ARCHITEC IENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION O O O O
Ew❑ I hereby affirm that I am licensed ander previsions or chapter 9(commencing Job Description
Z with Section 7").1 Division 3ofbe Business and Profeadions Cade.andmyliccmcis F
npw in full fn¢c andecn
5qz License a 0 Lic.0 7 REPLACE 3-TON A/C ����
nk,p DamO�Cuntractnr )
f ie� IundcrstanJ my pr'nsshel MusNDis public m7 k el d, AUG % '`OQ3
>yU
e o 1 Licensed Pmfcssional
OWNER BUILDER DECLARATION �U'�^'�
<5 1 hereby affirm that I am exempt from dor Cmilro mr's License law for the u
p o following reason.(Section 7031.5,Business and Professions Code:Any city nr county _
5 m which requires a permit to monomer.altar,improve,demolish,or repair any savmum
prior to its issuance,also requims the applicant for such permit to file a.signed statement
€=o that he i&Bsensedpursuant toftprvfaiorumthe Cmnractor5LicenwLaw(Chapter 9 Sq.Ft. Floor Area Valuation
Yk- (commencing with Section7MG)of Division 3 or the Business and Professions Code)or
y $ Nat he is exempt thcmfrom and the basis for Ne alleged exemption.Any violation Of 36922006 . 00
Section 7031.5 by any applicant for a permit subjNta the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred delta.(5500). p y yp
0 1,u owner of the property,or my employees with wages ax their axle compensation,
will do Ne work,end the structure is not intended or offered for sale(Sec.7044,Business _
and Prefea ions Code:The Contractor's Limnse law does not apply to an owner of TR 3 0 4 - ROUGH nS
prepeny who build&or improves thereon.and who docs such work himself or through his
own employees,provided that such improvements are not Intended or offered for sale.If. SOS — FINAL ELECTRICAL
however,the building or improvement is sold within one year of completion.Ne owncr-
builder will have the burden of leaving that he did not Wild or improve for purywse or 508 - FINAL MECHANICAL
sale.).
0 I,as owner of the propeny,am exclusively convecting with licensed contraction In
convect the project(Sec.7W.Business and PrOmsioru Codc:)The Contractor's Li-
cense Law docs not apply to an owner of property who Wilds or improves Ncmon,and
who containers for such prejeets wish acontraemr(a)licensed pursuant in Ne Contractors
License Law.
0 1 am exempt under Sec. ,B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury mss:of the fallowing declarations:
I have and will maintain a Cenificam of Conant to self-insure for Worker'sCompcn-
73700
ion,as provided for by Section 37M of Be labor Code,for the performamc of the
rk for which this permit is issued,
1 have and will maintain Worker's Compensation Insurance m required by Section
of the L iWr Coe,far dre performance of the work for which Nu perit is issued.
WorCtrmpcnsalimn Insann rand Policy namMraRrrier: „ ,
CERTIFICA ^OF EMP ION M M WORKERS'
COMPENSATION INSURANCE
(ITU section need our W completed if the permit is for one hundred dollar&(SIM)
(it less.)
1 ccnify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an as in become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
Wcome subject to the Worker's Compensation provisions of the Labor Code,you must
.Jz forthwith comply with such provisions or this permitshall W deemed revoked.
Z'O CONSTRUCTION LENDING AGENCY
�-+ Thereby affirm that them is a conswnion lending agency for the performance of
tY
the work fur which this permit u Lsrced(Sce.3197,Ci,C.)
GLender's Name
=z Lender's Address
U 0 1 comfy that I hate reed this application and state that the above information is
Iy coven.I agree to comply with all city and county Ordinances and state laws relating to
0 U building convection,and hereby authorise reprnentatives or this city to enter upon the
,hove-mentioned pmperty for inspection purpeacs.
H CL (We)agree 10 true,indemnify and keep harmlead the City of Cupertino against
N Iiabilities,judgments.c.Its and expenses which may in any way accroc against said City
U z in canxquencc Of Ne taming Of this per m'
APPLICANT UN STANDS N L COMP WITd ALL N N-POINT Issued by: Date
SOURCE REGU ONS !/[/9J�I�//n
Signature of ApplmanVCuntracmr G Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant or future building Occupant stare or handle harafdous material
as dcrined by the Cupenino Municipal Code,Chapter 9.11,and the Health and Safety
INquorernents�
de,Section 25532(a)?
❑Yea _IaNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant odor.,,building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hasardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
O Yes [qNo
1 have read the havaNmts materials requirememrs under Chapter 6.95 of the Califor-
HcaIN&Safety Code,Saturant,25505,25533 and 8534.1 un emac nd that ifbe Wilding
es net commlr ho nam bar It ism ponihirty o minty the o cupant of the
which LNm u comae cateorOccuparte Signature of Applicant Dale '
Owner or ao hound agent D2� All roof coverings to be Class "B"or better
CITY OF CUPERTINO
SRI - FURNA, CE lr,�LC
CUPERTINO PERMIT APPLICATION FORM
APN# 3Date:
bq -Zz - ao (
Building Address:
Owner's Name: n e Phone#:
Contractor: License#: 75 7 S ?-'5'Contact: Phone#�� 3_ Z 653
Applicant/C-eHE{ttstcr: S/o�S CF
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: C 3 /
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupanc} Group:
•
Qty. if
A licable Fee ID Fee Description Fee Group
BREMFURN Relocation of Furnace MECHANICAL
/ BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
/ MPERMITFEE Mech Permit Issuance MECHANICAL
/ PPERMII'FEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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