04060165 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
,,CONT CTOR'INFORMATIONg
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BUILDINGADDRESS: A & A PLUMBING Pc""'NO04060165
10704 GRAPNEL PL
OWNER'S NAME: PERMIT ISSUE DATE
dhi ALYSA HAY 924 E FREMONT AVE ois/ig/2no4
RIF ONE:
SANITARY NO. CONTROL NO.
(408) 738-8878
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
It" LICENSED CONTRACTOR'S DECLARATION � ,lob Descrl^(1011
u I herby affirm that I am lianset vision of Ghaplcf 9(cmmmcneing
WE wish genion )of Division Sof the evat a Professions Code.a9(merevociia ufY,lY\VPfI IIs
m roti(omen e m Z REPLACE FURNACE & ADD ASC
Liana Cl
`""'" JUN 23 2004
ARCHITECssD AT N
1 under y clans shell he used u lie memrd,
to
BUILDING
o Licensed Pmfessionel
5
OWNER-BUILDER DECLARATION
+� I hereby affirm Nos I ore exemon
pt from the Convector's License law for the
T'
00 fullnwingmmnn.(Section 7031.5,Business and Profession,Code:Any city or county
x m which".I.a Permit to consuum,eller,improve,demolish,or minor any snet.. 86800
ph.,in its issuance,also myuire,the applicant for such Permit to file a signed aUtemeal
that he I.licensed Fortune,to me rrviaiana or the corset,.,ueenu 4w(chapter 9 Sq.Ft. Floor Area Valuation
zts-S (commencing with Section 7000)of Division 3 of the Business am Profev'ons Cole)car
y — that be is eeerept dominant and she basis for the uleget exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a chill Penalty of or Occupancy Type
not mom Na"five hundred dollars(S500).
Q I,u owner of the property,Or my.11OYces with wages es their sok com,mand.n,
will do the work,and Ne structure u nut intended or offered for sale(Sec.7046,Business Requited Inspections
and Professns ioCode:The Comractoh License Law does not apply M an owner of 9. p
propertywho busiproorirepraysch improvements
doessuch wod himmool for W his
Own employees.dre u.ding.,i provehimpmwmcnu tient ear ofcded moBued for Weer,
however,Ne building or improvement is salt within of Wild or completion,the owner- ..
aAc.). will have Ne burden of proving that he tlitl not Wilt m improv for purpose of
sola.).
❑1.on owner a the progeny,am ealuiwly contracting with licensed comactom to
comwn the project(sec.7044,Business and prefesdm
ans Cade)The Conctee,Li.
cents w ladoes not apply an an owner of property who Wilds or improv thereon.and
who contracts for such Projects with a comranm(s)licensed pursuant m the Convacon S
License law.
1 am esempt under sec. ,B k P C for Nis mason
Owner Dau _
WORKER'S COMPENSATION DECLARATION
1 hereby effim under perkily of perjury one of the following declarations:
I have and will h undid a Certificmeof Conscntm self-insum for WorkchCompcn-
workfor which this fpPeermi tSatian 37000(Ne V Wr Code.far du performaOce of the
is issued.
1 hove and will maintain Worker]Compensation Insurance,as ingvired by Section
3700 of dm Labor Conks,for the performance of the work for which this permit is issued.
My Worker's Compensation insurance carrier and Policy number art:
carie'. "�ti'Z Polity Na.: 3 '
\V"A CERTIFICATE OF E%EMPPION FRO KERS'
COMPENSATION INSURANCE
(Iris scouter need nos hecempkud if the permit is forone hundred dollau(SIM)
or less.)
1 certify thvt in Ne performance of the work for which this Permit is issued.I shall not r
employ any person in any manner u as In become Subject 0 Ne w"rkeri Compensmlon
Law,of California.Dau
Applicant
NOTICE TO APPLICANT If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
.,,Z forthwith comply with such prvisimk or this permit shall W deemed invoked.
Z O CONSTRUCTION LENDING AGENCY
[-m vN-s I hereby sRrm Nat them is a combroutinn lending agency for the perommnce of
a i the wad for which this permit is issued(Sec.3097.Civ,C.)
Ik1Q Lendcr'a Nrom
IL lender's Addmus
V Q I cenify Nat I haw mad Nu N
is application and soot abs"aw information u
UU. f correct.e 1 agree to comply with all city and county ordinances and skis laws relating to
V building construction,to save.
Moietiestike buraili the Nis city tocnurUpon the
r U above-mentioned prPerty for inspection purposes.
(We)agree to saw,,do d kap harmless the City of Cupertino against
tiN liebilities,jutgmenu.c dexpenus Bich may in any way ecrneagaimssud City
U inconsequence of, panting of this it,
^ APPLICANT NDERSTANDS W OMPLY WITH ALL N-POINT Issued by: DOA
SOURCE ULAMONS.
Re-roofs
Si "nracmr Dau
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the applicant or future building occupant store or handle hazardous material
de0ad by de Cupenim Municipal Cote.Chapter 9.11,and the Health and Safety
ode.section 15531(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes QNu
Will thc applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
1aHu1dr&Sa1c,lyC=u
mit hazsrdous air comkminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
istrict?
Oyu q1(u
I haw mal ths kisinyu menuuntcr Chepter6.95ofmc Califon
15505.1noesIntcurmmlyhaw• aNtI s y responsibility M no IY de occupantof rhe
yuiinmcnu wh' hm mit iss"arta on amfieate,�iaGpan Signature of Applicant Date
b
DwnAll roof coverings to be Class"B"or better
Writ Dam
Community Development
��FF 10300 Torre Avenue
Com/ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De rtment
JOB ADDRE . PVFCMIT #
to-)oti ,-u „d / Pl 0-/ 0 60 1115-
OWNER'S N : 1445-4 /� V PHONE # 735- 152-1
GENERAL CONTRACTOR: 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 / 6 G ,117to $O/ 32
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
o actor Signature Date
1
r CITY OF CUPERTINO
v FURNACE/AC
IUPEkTINO PERMIT APPLICATION FORM
APN #
Building Address:
1 G�
Owner's Name:/ Phone #:
A/.
Contractor: Phone: License #:
,4 - 87 3 .2o13Z3
Contact:
Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech l�
L E' f�. .
Job Description: [�
� epl�e,n L o /�X•Is •�5
'r Go�.f' ,A�r•i�
Residential Commercial ❑
For Residential Installations:
Attic E' ls` floor ❑ 2nd floor❑
dhere to in set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation Plannin Approval Required Q
Cost of Project- oZ Type of Construction: Occupancy group:
OD
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Q if
A c ble Fee ID Fee Descri tion Fee Group
BENERGY Ener =ELECTRICAL
G
BREMFURN Relocation of Furnace ICAL
BREMACOVER A/C Unit> 10,000 cfrnICAL
BREMAIItHAN A/C Units <= 10, 000 cfrnICAL
BREMRECEPT Rec tl, Switch & Outlets
BSEISMICRE Seismic Fee ResG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE 151ag Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Licens — / BUILDING