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CITY OF CUPEWHNO
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BUILDING DIVISION PI✓RMIT
CONTRAM—' INFORMATION•,,
BUILDING ADDRESS:
A B S HEATING &AIR COND
PERMIT N003110065
1012
OWNER'S NAME:
334 SHAMROCK DR
PERMIT ISSUE DATE
JOHN WOOLFOLK
11Z13/2003
NE:
(408) 238-7178
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0
0
LICENSED CONTRACTOR S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Job Desc .' AL�®
wim Secti�q[g).f Division Sofmc Bmrmcssatd,WCditntCadc, and myliccnuis
Lcene aerree-ZD[{IC e%.P�(f/L�"u�ty
��Vtl iw.
REPLACE FURNACE
License Clans Lies C—!
Date t t - (� �� Contractor
NU V 2 0 2003
n r ARCHITECT'S DE ION
n / land my plans shall he used As p I" records
� •
BUR SING
Licensed Pmfessiand
i OWNER -BUILDER DECLARATION
�rM
I hereby affirm 1 oro exempt (runt me Contractors License Law for
i following mason. Permian 703 my
reaio on i Cndc: Any city or county
Business andmp
which rtyuias a permit re cnnslrua. alcor, improve.
construe, demolish. ore
ere. de any structure
$1300
? that heor its i used pursuant alsnto the the h NmiiI t a sig
Chaps rd-
rile a, Law (Chapter
the provisions of rar sucContractor
mmnmencing
Sq. FLFloor Area Valuation
ithSecltion 000)ofvim3ohecamnnesinirnuvwsCoderr9
of Ufr the
exempt
32616057.00
mare leis Ba
memento and basisallegelnemandon, AnyansGWC)of
li and me burs for alleged exemption. Any vintauon of
mel he is campy tang
Scanlon ]031.5 by any applicant rar a permit subjects the applicant to a civil penalty of
applicant bj
APN Number
Occupancy Type
not marc man five hundredane dollars
p y
❑ I, as owner of the pmpcny, or my employees with wages AS their.aole emnixemmiov,
will do me work. and me structure is not intended or offered for sale (Sec. ]DW, Business
and Professions Code: The Contractor's Liccnu Law docs not apply 10 an owner of
Required Inspections
property who builds or improves mcrcon, and who does such work himself or through his
Own employceS, provided that such improvemenu are not intended or offered for sale. If.
however, me building or improvement is sold within one year or completion, the owner -
builder will have the burden of proving mal he did not build or improve for purpose of
sale.).
❑ I, as owner of me mopeny, am exclusively contacting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) no Conmumr's Li.
cense law does not apply to an owner of progeny who Wilds or improves theman, and
who contracts for such pmjecu with a conactor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Date
_
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of me fallowing dcclaratione:
1 have and will maintain a Cceiflcam of Conteh to self -insure for Wmker'a Camped -
anion, az provided far by Section 3700 of me labor Code. for me pcdarmance of the
wad for which this permit is ismed.
❑ 1 have and will maintain Worker's Compensation Itsuancc, as required by Section
3700 of me tabor Cade. for the performance of me work for which this permit is issued.
'
My War i s C9mm
leouon Insunoec carticr end Polic bcr are:
Came 1A -W> Policy N ( IO2� -06
CERTIFICATE OF EXEMPTI MWORKERS'
COMPENSATION IN RANCE
(Thisuction need not becompleted if the permit isfm one hundred dollar. 5100)
or leap.)
1 ceNfy mat in the perfomsamc or me work for which this permit is immed. I shall not
employ any penin in any manner an as la become subject to the Worker Compensation
Laws of California. DOW
Applicant
"
NOTICE TO APPLICANT. Ir, after making this Ceni licate of Exemption, you should
become subject to the Worker's Cam penmlion provisions or the labor Code, you must
foMwi0 comply with such provisions or his permit shall W deemed rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affird- that here is a constmminn lending agency for the performance of
he work for which this permit is issued Pere. N97, Ci, C.)
Lender's Name
Lender's Add.,
1 certify that I have read this application and sure that the above information is
carted. I ague to comply with all city and county ordinances and sum laws relating to
building construction, and hereby amhorin representatives of Nis City to enter upon the
above-mentioned properly for inspcclion purpmes.
(We) to gram indemnify and keep hvmlem City
the of Cupertino against
liabilities, judgmcosi and cand expenses which may in any way accmc against mid City
m consequence
ec of of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH NON -POINT
Issued by: Dale
/ALL
vo�OpRC lt—EPULATINS.
l l
Re -roofs
nature or Applicants Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will But applicant or future Wilding occupant store or handle hazardous material
as defined by me Cupertino Municipal Calc. Chapter 9.12, and the Health and Safety
Code. Section 35532(.)?
Y. ria
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant tau equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
it havaot air contaminanu u defined by the Bay Area Air Quality Management
isuict?
all new materials for inspection.
f�
❑Yes EW.
,
1 have read me haaNnms mamrlals requiremeta untler Cltapmrei.95 of the Califon
nu Hcalm&SafetyCod. Seeuav 25505.25533 and 25534, 1 undersand hatifthe Wildin,
casual cm c rely have a mnaeL that it is my nexporwhility to noury me Occupant of the
IIICIImU51 Or Prior to I.... aft CmBC.. or Occupancy.
.'Signature
of Applicant Date
f3
All roof coverings to be Class "B" or better
Owner or authonmd gent
aam
CITY�OF
CUPERTINO
CITY OF CUPERTINO
FLJ RNACE/AC
P7RMIT APPLICATION FORM
i l
APN #
Date:
Building Address: I
z3 I
BREMACOVER
Owner's Name:
�o0L
Phone #:
rc�uc
A/C Units <= 10, 000 cfm
Contractor: �5
Phone: /, 7 / 7 (
1J O
-3b,71
License #:
Contact:
j Phone: „ y, U
t U
I Lj
Cupertino Business License #:
Building Permit Info:
BSEISMICOM
Bldg ❑ Elect ❑ Plumb ❑
Mech ❑
Job Description:n '
Elec Permit Issuance
Residential ® Co ercia ❑
MPERMITFEE
For Residential Installations:
—'
Attic ❑ 1" floor ❑ 2"d floor ❑
Plumbing Permit Issue
1 dhere to min setback requirement ❑
BPERMFEE
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) ❑
Plan Check Fee
Structural Calculations required for new installation ❑
BUSLIC
New installa 'on Plannin A roval Required ❑
BUILDING
Cost of P c .! Type of Construe
i
Occup
Strapped On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty.
,ADDlidabYe�
FPP TF)
U-- . --- —
BENERGY
BREMFURN
...... < <,U„
Energy
Relocation of Furnace
ree kirou
BUILDING
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
MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bld Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business Licens
BUILDING