04060060 CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT ev-ONTRACTOR�INFORMATION r>
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BUILDING ADDRESS: A tX H HEATING PERMIT NO.04060060
OWNER'S NAME: PERMIT ISSUE DATE
ILHNAO GANGA
HE SANITARY NO. CONTROL NO.
(408) 279-0722
ARCHITELTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=ore LICENSED COMRAC70R'S DECLARATION
4H� I heraby affirm in.t I un licensed u r provisions of Chapmr 9(mmmcncing Job Description
Szas wRSccuon] )af Di=ision3of Nc xv soul Pfofcuioro Codc,and my license
jn�FZ� LDiaemntREPLACE FURNACE ADD qMlYE
.
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CH CTSQE ATIOf
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x a a I undcruanJ my plain shell w used u punlic rtmrds JUN
/ 2004
'I- Licensed Pmfcuinnel
� OWNEm exempt frOEOn Commences
x i f ON
1 hcehy arTnn that 1 em exempt from the Convenors License Law for the p e A
pre following moon.(Section 7031.5,Business and Professions Code:Any cityorcounty BUILDING
K m which inquires a peomil w eonswcl arm,impose,demolish,or repair any swcwm a u VI
u-m poor In its iss...e..h.OsIm t the applicant for such pemlit I.files signed...torroal
that he is licensed pursuunuo the provisions of the Contractor's License LOW(Chapter 9 Sq. Ft. Floor Area Valuation
(co2
s�� Oat he is asam withsocrafrornon and of Division lf r O UC Busalleged
eta and profeson.Any
Code)of
i 3$ Net he is exempt Ocm(r.m and the buil for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects me applicanuo a civil penalty of 3"N N0a�6er 00 Occupancy Type
nos mart than five bundled dollars(55x0).
1,m owner of the property,or my employees with wages as their sole compensation,
will do the work.and me,structure is not intended or offered for sale(See.7W,Business
and Professions Codc:The Contractors Lice=Law does not apply m an owner of Required Inspections
propenr woo wase.rimpr..ss Oeroon.and wnodoe.seen wo,khmollfo,through his .
own employees,pmvided Oat such impm namons are not immided oroReled forule.It,
however.the building or improvement is sold within one year of completion,the owner.
builder will base Or widen of moving Oat he did not wild or improve for purpose of
sale.).
1,as Owner of On property,am exclusively contracting with licensed mntru ens to
construct Oe project(sec.7044,Business and Profusions Caske)The ConuacOrs U-
".^Law dors not apply O an vane,of property who wilds or imp..th enema.and.
who contracts for such projects with a contnnortq lienud pursuant to the Co aamors
License law.
❑1 an exempt mods,See .B h P C for this rcuon
Owner Dau
WORKERS COMPENSATION DECLARATION
I Imeby affirm under pevvy,of perjury arm of the following declarations:
401 hoe and will maintain a Certificate of Consent to self insure for WorkmesCompcn-
anion,u provided for by section 3700 of the Labor Code,far the,performance of Oe
work for which this permit is issued.
1 have and will maintain Workeh Compensation Insurance,as required by Section
3]00.1 On Vbor Cods.for On performance of Oe work for which this permit is issued.
g1yy'arkcrs Comfemmion lnaunntt cooler and Policyon am:
Omer (.(.�� I Awa *=:k!
CERTIFICAIEOF EMPM WORKERS'
COMPENSATION INSURANCE
(Thissectionaeed nothecomplemd ifrbc permit isfaronehundtaddNlars(SIM)
or less.)
1 ceNfy Oat in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so al to become subject o the Workers Compensation
Laws of California.Date
Applimm,
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must
Z forthwith comply with such prnvtswns or Ois permit shall W deemed evoked.
zCONSTRUCTION LENDING AGENCY
[-t .�. I barely affirm Oat dere is a construction lending agency lot On performance of
D: 7 the work for which this permit H issued(Sec.3097.Civ.C.)
S0 Undoes Nam,
0. Z Lender's Adders
U Q 1 unify Oat 1 have mrd Oil application and stun that,the above information is
If. F' cocoa I agree to comply with all city and county ordinances and suss laws elating to
0 wilding construction,and hereby Otorie epraenuuses ofthis city to enter upon the
a above-mentioned property for impaction purpose&
(We)agree to sae,indemnify and keep haemo,the City of Coperuna against
F' tn liabilitia.judgmcnu,cmas and expmucs which may in any way accrue against said City
U Z to consequmsen of Or granting of this permit.
^ APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOUR EGULATIONS.
e-roofs
Signal Ap man/Contracmr Dan
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or future wilding occupant smm or handle hazardous mamnal
as defined by the Cupertino Municipal Code,Chapter 9.12,and the i and Safety
.dc.Sec tion 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑rm In<
Will the applicant or fume building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
..t Im ardro s air contaminantsu do ncd by the Bay Area Ail Quality Management all new materials for inspection.
District,
❑Yes o
1 have mad the han niousmemrials requirements under Chapmr6.95 ofthe Calim,
nia HulOti Safety,C ,Sclooms 23X15,25533 ad 25534.1 tinders Nati!Uc building
docs n currently an a tenant Om it is my responsibility t ly ..Pant of Or
require W ' hmmthcmct isau.c.cf.ccrifiwm f upon Signature of Applicant '' Date
Owner auth.nrcd agent Dam All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
I aN Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Buil ding Department
JOB ADDRESS: PERMIT# a O
OWNER'S NAME: PHONE # 4t& Z Z
GENERAL CONTRACTOR: FAX # 4/67 -t�D
I am not using any subcontractors: ^' 0
Signature IVDate
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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE /AC o o �,
PEkTINO PERMIT APPLICATION FORM
AAPN
Uit — Datc:
369 . 31 - 0,A0 (- 7-6)
Buildiu, Address:
103 9S ---
Owner's Name: Phone #:
Conu'actor: f License #:
Contact: Phone #:
_
DA 46 PAELP _ 0279- 0 7aU _ --
Applicant/Convactor:
Building Permit Info:
Bldg _ Plumb _ h
Jul) Dcscriptiun: —
Residcmi:d: Z�Lb V 6L'T- Commercial: —_
Sq.Ft. Floor Arca: $/Sci.Ft.:
Architect/Engineer: — — Valuation: '](/,eye�� --
Type of ConsuRuction: Occupancy Group: /--- --
A i )lic,l Fcc 11) -ec Description Feu Group
BENFRGY Enerov BUILIDNG
_ BREMFURN Relocation of Furnace MECHAMCAL
_ BREMACOVER A/C Unit > 10,000cfm MECHANICAL
_
—BR EMA—IR HAP. A/C Units <= 10, 000 chn MECHA�INICAL
BREM_RECEPI' Reml, Switch K Outlets ELECTRICAL
— — BSEISMICRE Seismic Fce. Res BUILIDNG —�
_ EPERMCTFEE Elec Permit Issu;tnce ELECTRICAL,
N1PERMITFEE Mech Pertn_it Issuance MF,CI-IANKAL
PPERA I[TFEE _--- _Plumbing Permit Issue PLmmB1IvG
— BP� ERNIFEE Bldg Permit Fees - - BUILIDNG - -
BPLANC'HK Plan Check Fee BUIL_IDNG
-- BUSL[C — �Busincss License BUII_IDNG
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