05090013 CITY OF CUPERTINO tea .«
BUILDING DIVISION PERMIT .-CONTRACTnR INFORMATION Ca
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BUILDING ADDRESS: AAA FURNACE & AIR CONDITICffftUO05090013
1
OWNER'S NAME: PERMIT ISSUE DATE
LARRY MATTEVCIG 1712 STONE
ONE: SANITARY NO. CONTROL NO.
(408) 293-4717
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
d" .LICENSED CONTRACTOR'S DECLARATION
F❑ I hereby affirm that I am licensed under provisions of chapter 9(commencing Job Description
iui with Section 70K)of Division 3 of the Business and Professions Code,and my license is
n« inrallfors ane err n, qq 1/r RELOCATE FURNACE 12 .DUCTS GAS LINE
License CI /f i/ f a/N Lk.N •I
Dam AT/� (.' Commcwr 3 .
"�J ATCHf1ECTS DEC RATION
e 1 unnermand on,plans•ha11 to it as public rttnrds
�ed
u y Licensed Professional
u< OWNER-BUILDER DECLARATION
<J
S 1 herebynaso .ffirm(Scc un 1 am exempt from me cnnuamoo :Any c Law for the
-C o following rices a permit
01131.5.liminess and va,de um Code:Any city of county
id m which its iires a permit w UlGeS Loualar.improve,h pCotil t or repair ani structure $6000
FIe prior In in issuance.also requires te applicant for such pertniuo file&signed sulcmcm
Ep�o thatW is licensed purumn w the pmviaions of he CMIMGG r,License Lao,(Chapter Y Sq.Ft. Floor Area Valuation
z (commencing with Section7fM(G of Division 3 of the B usi^eas and PraRssions Cote)or
i Nat he I exempt therefrom bdoeexemption.and the mb for alleged exemption.Any violation of
Section 0031.5 by arty applicInt for a permit subjects the applicanfm a civil penalty of r Occupancy Type
not mom man five hundred dollars(S500).
D 1,as owner of the property,or my employees with wages as their Sale compensation.
willdothework and theawctumisnotintendedoroffered ftrask(Scc.70 ,Business v('
Required Inspections
and Professions Code:The Contractor's License Law does not apply to m owner of
pmpcny who builds or improves thereon,and who does such work himselfortimugh his �V ° { �i
own employees.provided mat such improvements are not intended at offered for We.IL •yt as t1.y
however,me building or improvement is Sold within one Seat of completion.the owner- yt4.0ixt t
builder will have the burden of proving Nal be did not Wild or improve far purpose of
nate1. ��T a
I.as owner of he property.em exclusively connecting with licensed contractors to 3 2005
convect the project(Sec.7044.Business and Prefusiuns Code:)The Conlrecwr's Li- yJ
ceve Law does not apply In an owner of property who Wilds or improves demon,and, !At
wbac6 for such projects with aconvacmr(s)Iiunumm
licensed Conti;1� i��
I.Icense nu Lxw,
❑ exempt xcmpt under Sec. .B&PCfor this revan C7 {
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm ander penalty of perjury one of the following declar lions:
1 haw and will maintain a Cenifieau of Consent a self-insum for Workers Coal
137,00
ion,as provided for by Section 3700 of the labor Code.for the performance or the
rk for which this promi,is issued.
1 have and will maintain Workers Compensation Insurance.u acquired by Section
of me Labor Cafe.for Ne performance of the work for which this permit is issued.
Worker.Coontensed..homnme artier and Policy number asrrier:vim"T�/TC./tel//tai✓ Policy No.: aL-=�
CERTIFICATE OF EJ(EMMON FROMWORKERS'
COMPENSATION INSURANCE
Mis section need not ho completed if the permit is for one hundred dolhrs(SIM)
r Ictis.)
I certify that in the performance of tic work for which this permit is issued.I shall not
employ any perxxn in any mdnner so a an become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Ceniriatc of Exemption.you should
become subject w the Worker's Computation provisions of the Labor Code,you must
.JO forthwith comply with such pmvisinm or his permit shall be deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
I hereby affum that here iso construction lending agency l'nr the peromancc of
C he work for which this permit is issued(Sec.3097.Civ.C.)
fa7 Lcadcls Name
n• Lender's Address
=)Z
U Q 1 certify that I have fad Otis application a0W some mat dC&hove information b
Lt.P cmma 1 ague to comply with all city and county ordinances and sum laws Mating w
0U building convection,and hereby authome repusentalwa of his city to enter upon to
Y'W move-mcnuoned property for inti purposes.
(~C WC)agree to sane,indemnify and keep harmless he City of Cupenum against
Iq liabilidea.judgmems,casts and expemca which may in anyway acefue agamtsaid City
U Z APPLICAuNT UNDEof Bic RSTANDS AND ranting of thus TWILL COMPLY WITH ALL NON-POINT Issued by: Date �f�2 6,
SONRCE REGULATIONS. )
/�, .a->.� �'Lf:.c�r-, _ B� -c2��y Re-roofs �/�
g sure ofApplicaHAZWRDOUS ATERIALS DISCLOSURE Date Type of Roof
Will the applicant ser future building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 35532(&)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �3a
If a roof is installed without first obtaining an inspection,I agree to remove
Will ds applicant nt,ums I building occupant esu equipment il dMana which g
it hazardous air contaminants u nefincd by 0C Bay Arta Air Quality Management all new materials for inspection.
islrin7
Dyes
I have mal he hazard smawrialsuquiromens under Chepwr6,95 of the Cslifor
niaHealth&Safmy Cone,Secvons 25515.25533 and 25534.1 understand halifthe Wilding
does nal currently hoc a Count,hat it IS my map sainlity w notify the occupant of the
mquiwments which must W met poor w issuance of a CeruOaue or Occupancy. Signature of Applicant Date
All roof coverings to be Class"B" or better
o er ser authon'rcd agcm Dam
.� Community Development
- 10300 Torte Avenue
-% Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT#
/ zf,, true u .fib;ao l3
OWNER'S NAME: PHONE # j
GENERAL CONTRACTO : FAX #
I am not using any subcontractors:
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 ]o
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Co tractor Signature Date
CITY OF CUPERTINO
m ,'- F URNACEi. C v .
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
/D o k A 1z as
Owner's Name: Phone #:
Contractor. License#:
G 76 dv op
Conta t: ` Cupertino Business License #:
AZA
Building Permit Info:
Bldg ❑ Elect Q-� Plumb 0 Mech
Job Description:
g
Residential ❑ Commercial ❑
For identialInstallations:
Attic I" floor ❑ 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Pro'ect: Type of Construction: Occupancy group:
F
d ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
cation ! Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfrn 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