05020115 CITY OF CUI'ER'I'INO matt.r�' >at' •^'" '"�+ .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
nulLDwc ADDRuss: RESIDENTIAL HEATING AND A/ rElk '" 5020115
2330 HOMESTEAD RD 4 112
I NER'S NAME' PERMIT LSSUE DATE
KAREN HA 65 CRISTICH LN 02/16/2005
ONE: SANITARY NO. CONTROL NO.
4083774073
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
;Op LICENSED CONTRACTOR'S DECLARATION
C Z C I hereby affim that r 1 am licensed under untig.M or Chapmr 9(commencing Job Description
with S
e<b ection 7IXM)ofDwiaion 3 of the Business and Professions Code,and my license is
u in roll for:eInd Or c REPLACE AIR HANDLING. UNIT
Liccnx Lie.x O
=F,p Dam + Ganlmttof
sty ARCHITECTS DECLARATION
'd W U I understand my plans shall he used as public records
�Otn Licensed Professional
g OWNER-BUILDER DECLARATION
<I 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Secdun 71)31.5.Business and Professions Code:Any city or county
<m�s which requires a permit ser convect,alcor.improve,demolish,or repair any structure $2185
prior to its ismance,also equines the applicant for such Permit 1.file a signed statement
< that he is Licensor pursuant to the pmvisionsofthe Contractur'sLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
eFp (commencing with Section 79R)of Division 3 of the B usinea and Professions Code)or
that he is exempt thcefrom and the buds for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to•civil penalty of 3 Z65aQulniberO0 Occupancy Type
not more man five hundred delta.(5500). P Y YP
❑I.as owner of the property,Of my employees with wages az their sole compensation,
will do the work,and the swcmm is not intended or offered for sale(See.70 OL Business
and Professions Code:The Contnnor's Liccnx Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees.provided that such improvements are not intended or offered for sale.If.
however.the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving but he did not Wild or improve for purpose of
sale.).
1,as owner of the pfmfeny,.Business sivnd enmessi ns wire licensed cunoanoss toe.- -
tense La the Project(Sec.]Odd,wneofand Professions Code:)The Contractor's Li;2
cmLawdoes not apply r roan with
a cofpfoporay who sedpurlds rimprovex themun.antl;
wbense Lacu for such projects wily acmntnctor(q licensed pursuem mthe Conuacmrsr / '
License law, ft
❑lam exempt under See. .Bh PCfor this mazoo W/ ,
owner Date Il,
WORKER'S COMPENSATION DECLARATION s •• {:' I J(
Ihereby affirm under Penalty of perjury one of the following tlttlaratifude 444:::111 /t y
❑I have and will maintain a Certificate of Comm to self-ilium for Worker's Cumpen- L'I 1111
ration,az provided for by Section 3]00 of the labor Code,ran the pertonmanm of the Egli
W,
for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance.u required by Section -
70)of the Labor Cale,for the performance of the work for which this permit is issued.
My Worker's ComypensatiioonInsurance carrier and Policy nuummkraam::-�j�
Carrier: Cl..\� 1'41.(101 Policy Na.: 001—kWe:i
CERTIFICATE OF EXEM MON FROM WORK ERS'
COMPENSATION INSURANCE
(This action need not W Completed if the permit is for one hundmd dollars(SM).
fir It..)
I cenlfy that in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner so u to become subject to the worlocs Compensation
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 the Labor Code,you most
�z forthwith comply with such provisions or this permit shall Lou deemed evnked.
ZO CONSTRUCTION LENDING AGENCY '
I bereby Into that tberc is a convection lending agency for use perfurm um,of
314 > the work for which this permit Is issued(Scc.309].Co,C.)
D Q lender's Name
Lcndcrs Address
z
;J I certify Nat I have read this application and sine that the salve information is 1
y U torten.I agree to c comply with all city and county ordinances and tam laws relating he
�(J Wove- construction.and hereby p rcpruenutives of this Lily to enter upon the
W anovc-(We)
propertysave for impcni an keep ha.
(Wc)eget m cost,indemnify and keep hay in an the City ro Cupertino against /6
rZ
Liabilities,judgments,costs
randand expenses which may in anyway accmc against raidCity
J,'� A consequence of the granting of this permit. �^
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaDam
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof'
Will too applicant ser(Mune building Occupant score tar handle bacardous
and Safety Of
defined by the Cupeninn Municipal Code.Chapmr 9.12,and the Hcahh and safety
oda.Seniors 25532(a)? - All roofs shall be inspected prior to an roofing material bei.
O year 0 N P P Y g beinginstalled.
Will the applicant or future building occupant uxequipmemor demes which If a roof is installed without first obtaining an inspection,I agree to remove
it ha'vrdnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes ❑No
I have mad NC hmaNrus mnermix rtquiremenes true,Chapter 695 mf the Califor- w / ` f�f.
3 and
d!dor
Wilding
J I notN urre tlyyhavea mnan,mat if iis2my3responith l ty a n ull,be nocupart Or the �AVgaimmentswhichmughe,metpoortoiaztaneeofaCertificateofOccupancy Signa[ureofApplicant Date
Owner ser authorirnd agcm Date All roof coverings to be Class "T or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
AUPERTINO
Building Department
JOB
aADDRESS:
a 3Q ��OiYI -'LC��� � 2 PERMITO# Sid Z
OWNER'S NAME: MrS . \—1 PHONE # (t,50)b�y- JEE''�
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: ��^ ^ �0. R)a l lD C)S
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
As Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO �� o
FURNACE/ACCITY OF
6 S
SUPERTINO PERMIT APPLICATION FORM
APN # Date:
�a �s9 o � a
Building Address:n� ^
Owner's Name: Phone #:
Mrs. CA n Gaso ItI
ontractor: P one: ����3�-1 0 License #:
es'rcl�nl al Nea+ AIS \nc. "1 �555� ?
Contact: Phone: Cupert o Business License #:--- -
W-e�l 3� 1- 10
Building Permit Info:
Bldg Elect Plumb MechI
Job Descrill 'on: \
Residential --,..:__Commercial _
For Residential Ins allations:
Ajj�Attic ❑ 1" floor"W 2nd floor❑
dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural Cates) C1 - --— - --
Structural Calculations required for new installation ❑ .. .
New installation Planning A2proval Required ❑
Cost of Project: a 1S uType of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Cl Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIltHAN 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 IssueW
BPERMFEE Bldg Permit Fees BPLANCHK Plan Check Fee Business License