05060040 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT ¢CONTRACT- NF
OR IORMATIyO
BUILDING ADDRESS: AIR QUALITY HEATING & AIRC RMIT ND.05060040
OWNER'S NAME: PERMIT ISSUE DATE
1 PATRTMA f,- PP.TP.R r'T417
NE:
SANITARY O OL NO.
ARC HITECTIENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LOo LICENSED CONTRACTOR'S DECLARATION
WU 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
E withakCtion7Bl10)of Division 3 ofthe Business and Professions C,o/de,and my license is f� II �®
in fall cffeal ei �Y� REPLACE A/C 1 ` I / IIfn}lIf
,._ License Claes Lim.N—f-r�—s---rte— t�;♦l� J
nF p Dale Contractor 11k i1
J ARCHITECTS DECLARATION
WV 1 understand my plans shall be used as public records
o Licensed Professional
OWNER-BUILDER DECLARATION
q 1 hereby infirm that I am exempt from Ne Contractor's License Law for the �yyp) rlI }i1 I,.,� reef
0 o following moon.(Section 7031.5,Business and Professions Calc Any city at county
X 2 which requires a Permit to construct,some,improve.demolish.or repair any svuaum ` _}/ I`\ a—
Fir prior or its issuance.also requires the applicant for such permit to file a signed statement .— ,as V A
< that heislicensed pursuant to the provirronsafthe ContractorsLocomLaw(Chapter 9 Sq.Ft. Floor Area Valba[lon
9RFre (commencing with Section 7000)o(Division Sof the B usincss and Professions Cade)or
i that he is exempt therefrom and the baso for tine alleged exemption.Any viola0on of
section 7031.5 by any applicant fon permit subjects the applicant to a civil penalty of 3g�IlIgQglg3'¢er00 Occupancy Type
not mom than rive hundred dollen($500).
0 1,net owner of the property,or my employees with wages res their sole compensation.
will do tic woo.and decsaueure is not intended oroRead tarsale(Sec.7004,Business
and Professions Cade:The Coaaactues Liana law does not apply In an owner of Required Inspections
property who buildwrimproves thcmon,and whodoessuchwork himself or through his
Own employees.provided that such improvements arc not intended oroRered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improv for purpose of
sale.).
0 1,as owner of Its,property,am exclusively contracting with licensed convectors to
construct the project(Sec.7044.Business and Professions Code)The Comractues Li-
ceme law docs not apply an an owner of property who builds of impfom thereon.and,
who contracts for such projects with a contraction(s)licensed pursuant to the Contnnors
License Law.
1 am exempt under Sec. .B h P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby effete under penalty of perjury one of thk following declarations:
1 is and will maintain a Cenifam of Consent o sel6insure fon WonkeriCompcn-
7E]
ion,as provided for by Section 3700 of the Labor Code,for the performance of do
rk for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
W of the labor Code,far the p nmorm rice of thc work far which this permit is issued.
y Workers Compensation lnsumnce earticr radPalre numberane:
rver. G �,V obey No.:
CERTIRCATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is foron,hundred dollars(5100)
m less.)
1 certify that in the Kafoonsne.of the work far which this permit is issued.1 shill not
employ any person in any manner en as w became subject in the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in thc Worker's Compensation provisions of the labor Cade,you must
.JO forthwith comply with such provisions or this permit shall W deemed revoked. „
Z " CONSTRUCTION LENDING AGENCY
(-..N., 1 hereby aMfm Nm them is a construed..lending agency,fee the Kifarna.ce of
cd the work for which this permit is issued(Sec.Bill.Civ.C.)
[Ll Q Under'.Name
G
z Lender's Address
U
[)O 1 ttpme,Nat I hast mad this application and sure Nn Ulm above information matiun to
IyU cortccL1agreemcomply with all city and county ordinances of and cute laws relatinge
p U x1howngconsmedpro and hereby ecilnosrcprcsematives of this city to enter span the
,rte abovomentioned to snow,
an keep ea
H4. (We)agree 1.owns indemnifyand hap harmless the City of Cupcnitaagunst
h inconsequence
o sequen eoftheerasing of this Permit. may in any way score again,pig City
L)z APPLI quenecofthegrantingosthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date —`-j'
SOURCE REGULATI?A
2 A� 'f__ ti�� Re-roofs
sig.a'taee dAp banurComeacon Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building occupant stare infrasonic hvallous material
as dcfncd by the Cupertino Municipal Cods,Chapter 9.12,and the Health and Safety
ale.sceia.15512(.)7I All roofs shall be inspected prior to any roofing material being installed.
0Y. �Na
Will the applicant or future Wilding occupant use equipment or ocvices which If a roof is installed without first obtaining an inspection,I agree to remove
it haiardous air contaminants as defired by the Bay Area Air Quality Management all new materials for inspection.
7M,vot?
0 Yes - N.
I have mail the hvardtion maredid,rcquincrecr s Cook,Chapter 6.95 of the Califor-
lic.1 &SafetyCom,Seedom 255)5.25533 end 25534,1 understood that if the building
s not curently hart a tenant that it is my responsibility to nnfily the Occupant of the
uinemcnu which must be set pn;oetuissuanceof aCenlfam of occupancy. Signature of Applicant Date
� All roof-coverings to be Class"B"or better
n r r authnnxeJ age Dam
Community Development
0 Torre Avenue
CupOertino CA 95014
Telephone(408)777-3228
�
CITY OF Fax(408)777-3333 UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
o [✓Gt�o� C-7-1 - USa 'ul Z36tid
OWNER'S NAME: ti r,"c _ e1e r CZ�s, PHONE # � _ 2
GENERAL CONTRACTOR: 4 r ' ti 6;4, FAX #
I am not using any subcontractors: �? �/L- D
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
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
ODE,
FURNACE/AC C7 ''7'"° v �a
CUPERTINO PERMIT APPLICATION FORM
APN # 3�y Date: ., 02 �_
Building Address: / /
So oGt/GCio+ GT -
Owne?s Name: Phone #:
Contractor: License#:
!�/
Contact: Cupertino Business License#:
Building Permit Info: C.
Bldg ❑ Elect Plumb Ed Mech
Job Description:
Residential PJ Commercial ❑
For Residential Ins Mations:
Attic ❑ 1s` floor 2nd floor❑
Adhere to min set back requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
a 1 aS . 0 °
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
13SEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING