04010026 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ikCONTRACTnR INFORMATION
BUILDING ADDRESS: GOSAL HEATING&AIR CONDITIO �`WT"04010026
OWNER'S NAME: PERMIT I55UE DATE
MAR
ONE: SANITARY N0. CONTROL NO.
(510) 441-2318 ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSEDCONTRACTORS DECLARATION Job Description
u1 hereby affirm that I am licensed under pmvisiom of Chapter 9(commencing
i with Scaion 7PM17 of Division7of the nusincee and Profcssinm Cndq end myliccnse is
jai'� mm�ra'•k�-y� erten, y/ REPLACE FURNACE AND DUCT WORK
Lions 06y �' —2 Lk Y
Da came �—
�SS RC all tic
DEC TION
D. I understand my plana shall W reed u 1i tic seconds
JyU
g ii LiccnuJ Prnfcssionel
5 OWNER-BUILDER DECLARATION
2 1 hereby affirm that I am exempt from the Contractor's License Law for the
p 0 following reason.(Section 7031.5,Business and Pmrcxsions Code:Any city or County
m which requires a permit to construct.alter,improve,demolish,or repair any xaucmm
_Zan priormits issuanm.alsu rcyvirrs lM applinmfor such px:rmiuo Blcasigncd gatemcnt
ppthat he is licensed pursuant it)the provisions(if the Contractor aLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
Y�$ (commencing with Section 7(100)oI Division 3.(the Buxineaand Professions Code)or
st`c— Na he is..emit therefrom and the buts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant Or a civil penalty of 3M1S0gU63@cr00 Occupancy Type
not more Nan five hundred della.(SSW),
01.as property,of my employees with wages utheirslcaompsmation,
will do the work.and the structure is not intended of offend for sale(See.7W.Business
and Professions Code:The Contracmni License Law d.nut apply to an owner of �'� �� wired Inspections
property who Wildsm I.,..lWmon,and who doesauch work himself.(Buough his A
own employees,provided that uch improvements ane not intended oroQered for sale.If. l
however,the building or improvement is sold within one year of COMPlc60ve thn,the owner. O 200
builder will haw buNcn of proving that he did not build or improve for purpose of aj I
sale.). u/k�1 d
1 k
❑h as Owner of the property,am exclusively contracting with licensed eonuacmot to w
construct the project(Sec.70m sour
14.Beat..and PrpfossiaCofl The Ocami Li BUILI)IN
come law does not apply to an owner of proper,who Wilds or improves Ncteon.and
who conuacts far such projects with a conosmr(s)licensed pursuant to the Contractor's
License law.
❑1 am exempt under Sec. .B&P C for Nis mason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury an of the following declarations:
1 have and will maintain•CcNnnu or Cement b ul6inaure for Wodee.Compen-
sation,as provided for by Section 7700 of the labor Cade,for Ne performance of the
work for which Nis permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this Nounit I$issued.
My Worker's Compenssatio.nl/ns'u�rance canricr and Policy number art: 'may
/t-� Policy No.. I SQL
DV CERTIFICATE OF EXEMPr10N ORKERS'
COMPENSATION INSURANCE
(TMs section need not W completed if 1M Permit is forme hundred dollars(3100)
in less.)
I Certify that in But performance of the work for which this Permit is issued.1$hall not
employ any person in any manner so as to become subject o the Workers Comfcm2 iOm
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Be Labor Code.you most
,Jz enowi N comply with such provisions or this permiuhall W deemed revoked. -
?O CONSTRUCTION LENDING AGENCY
'r. I borehy afnrm that the.Ii•consuuetinn lending agency for the penfunnnwe of
a 7 Ne work for which this permit is issued(Sce.3DB7,Civ.C.)
li] A Lender's Namc
2 Lender:Add.
U O 1 certify Nu 1 have read this application and sue:that the.have information is
Wf—' Conrcct.1 ague to comply with all city and county ordinances and sure I.
relating m
0 U Wilding construction.and hereby archaise rtprountniva of Nu city to Cour upon the
LT7 ahave-mentioned property for inslx:c0on purpose,
F 0. (Ws.)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgmcma.coats and capcucs which may in any way recruc against mid City
U z in consequence of the granting of this permit. / G
r. APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S C REGULATIONS.
Re-roofs
atureof Applicant/Conm or I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applies.,or future building occupant eros or handle hazardous material
as de fined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Semon 25531(a)1All roofs shall be inspected prior to any roofing material being installed.
❑Yu PNa
If a roof is installed without first obtaining an inspection,I agree to remove
Will the air contaminants
mantra building by ft D esu equipment or devices which
it hvaAnm air conmminanu u dcfncd by 1M Bay Area Ain Quality Management all new materials for inspection.
uictt
❑Yes No
I have read the have nsmaterials requirements under Chapter 6.95 o(the Califor.
nia Hcalth&SdetyCode.Sections 25%5,15533 and 25534.1 unda.tand the if the Wilding
dao oat currently have a unant, at it is my nrs,radifly in nosily the occupant of the
re r menu whieh mag='r cemne.tcof actrPaney. Signature of Applicant Date
/ All roof coverings to be Class "B"or better
o er m aathod.ed ascot Date
CITY OF CUPERTINO
am�s FURNACE/AC o �jDoab
UPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
�r7
Owner's Name: M � -U hone#:
Contractor: one: g 0 `I`I 1-231 Q License #:
4�6 S,q-G rt-'er[k b
Contact: k--7
„ G Phone: S t o K-01 X71 Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: G� � UGT (,1-6/1 k I Js�4t�q 1�7
/-Z-
Residential g Commercial ❑
For Residential Installations:
Attic Q 151 floor ❑ 2"d floor❑ to
Adhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑1Additional weight (structuralEl calcs)
Structural Calculations required for new installation El
New inst llation Planning A val Required ❑
Cost of rojectt y9 91
Type of Construction /�: Occupancy gr p:
Strapped Platform ❑ Bonded LJ / Sq.Ft. Floor Area.
New Location Re lacem t
Qty. if
Appljl5a& Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
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
( 12 MPERMITFEE Mech Permit Issuance MECHANICAL
all PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
USLIC „ Business License BUILDING