03100144 CITY of CUPEaTtNo
BUILDING DIVISION PERMIT } CONTRAC I OR INFORMATION '
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BUILDING ADDRESS: SCHAUMANN AIR CONDITIONING,PERMIT NO.03100144
OWNER'S NAME: HEATING & PLUMBING INC PERMIT ISSUE DATE
"E` (408) 428-0640 SANITARY NO. 9 2 CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
iop LICENSED CONTRACTORS DECLARATION
U G 1 hefcby afnrm Ihn[am licensed under provisions of Chapter 9(commencing Job Description
;q U wish 5caionTfllM))nf Division Juf IIIc Busme.v end Pmfcssinns Cadc.an dm liecnscin
to
�i«�I>ra`.` f" 20.3 L /- �� 3 REPLACE FURNACE & A/C
i 1=o Date Contact,
QQ ARC�I�I1,T,LCTS DE ATION
i 2 u rst J myglaBSaLaM M use u public records
at
s
'l- LreenuJ Pmfessmnal '
OWNER-BUILDER DECLARATION
I 1 hereby affirm that I am exempt from the Contractors Lieenu Law for the
100 following reason.(Section 7031.3.Business and professions Cade:Any city or County
d$� which form.a permit to construct.altar,improve,demolish,or¢pair any structure
rim prior mots issuance.also requires the applicant for such permit to file a signed statement
that he isbeemcdpursuanttosheprovisionaofNeContractoraucenaelaw(chapter9 Sq. Ft, Floor Area Valuation
;FO (commencing with Section 7")of Division J of the Business and Professions Code)ur
Nat he is exempt therefrom and the Was for the alleged exemption.Any violation of 32659057 . 00
Section 7071.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than fiva hundred dollars(I500).
❑L as owner of the property,or my employees with wages as their sole compensation.
will do the work,and the strumum is not intended or offend for sale(Sec.7044,Business
and Professions Code:The Contractors Licame Law docs nut apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employces,Provided Nm such improvementsare not imended oroRcred for sale.If.
however,the building of improvement is sold within one year of completion.the owner
builder will have the burden of proving that be did not build of improve for purpose of
sure de
❑1,as owner of the Psupeny,am exclusively contracting with licensed contractors In
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li.
cove law does notch pr man owner of property who builds or ant to cs Marcum.Cormic and,
who contracts for such projects with a contractaf(s)licensed pursuant to dre Contractoh
License law. /
(]1 son em exempt antler Stt. .B&P C for this lesson
Owncr Date
WORKER'S COMPENSATION DECLARATION L
1 hereby affirm under penalty of perjury One,of the following hchtaions:
.:haw and will maintain a Certificate of Consent to act f-insum for Worker'sComps
en-
ut
ion,as provided for by Section 3700 of fNe labor Code.for the performance of the
work fof which Nu permit is issued.
I have and will maintain Worker's Compensation Insurance,u tortured by Section
371W of the labor Code.for the performance of the work for which this Femurs issued.
My Worker's Compensation Insurance Cartier and Policy number art:
Came. ./ Pyy1B�ccy No,:���'�� •
CERTIFICATL•OF EXEMPrfON FROM WORKERS' ,
COMPENSATION INSURANCE
(This•amino need not M camPleted Rthe Permit is for one hundred dollars nhar
leu.)
I certify that in the perfinmanee of the work for which this Permit is issued.I shall not
employ any pecan in any manner so as w become subject o the Workers Compensation
Laws of California,Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker'a Compensation provisions of the Labor code,you must
�Z forthwith comply with such provisions or this Permit shall be deemed evoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there its comma"nn lending agency lar he Performance of
as 7 the work For which this permit is issued Sec.3(197.Civ.C.)
A 0 Lender's Name
7 Z Under's Addis
C) 1 certify that I have Fred this application and lute that Ne about information is
y F correct.l agree to comply with all city and county ordinances and sate laws relating to
�U building construction,and hereby euthorimmpnxnativrs of this city to cater upon Ne
W "bow-mentiuned pmPerty for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r N liabilities,judgmena,costs and expenses which may in any way accrue against said City �h
;J,7, in consequence of the granting of this Permit. V
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION-
All /e- -o Re-roofs
ore drApplicantlConaractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or(Cots.building occupant sten or handle hanrduus material
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code,Section 35533(a)? g}J/ All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicam or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.;harardous air coreeminants a fired by the Bay Arca Air Quality Management all new materials for inspection.
inri,t?
C]Yea
1 have read]the hvardnus materials requirements under Chapter 6.95 of the Cahfrr
ria Health fk Safety Code,Sections 35505.35533 an135534.1 underswnd Not if Ne building
does not currently haw a tenank it is my responsibility,us nouly the occupant of the
rcquiements which most ' rw'ssaanec are Certlficae of Occupancy. Signature of Applicant Date
/,0,t 0
Q roramlimiacdagent Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
FUMNACE /AC
CUPEIZTINO PERMIT APPLICATION FORM
APN# 7�/ -c� - Date: l o
Building Adddress
ZZ
Ow er's Name: Phone#:
t 0 - 773-
n c C )W� License#: -7 3
um
tact Phone#:
f c0 - N23 0
MAp licant/Contgtor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: ' K- /q/Q-- Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: c3
Type of Construction: Occupanc p:
Qty .
A li b Fee ID Fee Description Fee Group
IL BENERGY ner -BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAHUiAN A/C Units <= 10,000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch&Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMrrFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Pemnit Fees BUILIDNG
BPLANCHK Plan Check Fee BUELIDNG
BUSLIC Business License BUILIDNG
C) 2-