03070137 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORjNFORMATION
BUILDING ADDRESS: CONDITIONED AIR PERMIT N003070137
s OWNER'S NAME: 1701 LITTLE ORCHARD ST PERMrtIssuE DAT,
W
Al PAT TAKWAMPIMT
NE: (408) 291-2,2,20 SANITARY NO. CONTROL NO.
AR CHITECffFNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION
m 1 hereby affirm that 1 am limn..��.999 under P s of Chapter 9(commencing agyCfiypll on
Q� wilhS tion70TN1)nf Division Sof Nc�jlsinewnd err cs io s Cody an dm liy ccnsis HL�®
in mor ander I ✓ 3 "!1/- ADD ASC
� Littnu ss Lic.N
Data
- - Gantt ter F E B
Q�Q
CHITS S GLA D 0 5 2004
2 1 undcrstanJ my plans nM1all be as public mcnrJs
Oy
3 0 LiccnuJ Professional BUILDING
'IT
OWNER-BUILDER DECLARATION
.�i y 1 bcrchy affirm Met I on exempt from de Contractor's License Law for the
O O ullawing name.(Section 1031.5,Business end Professions Code:Any city or county
x m� which requires a permit m mnawcl,arm,improve,demolish,or repair any xwcmre
priofm its issuance.also requires the applicant for such Vomit m file a signed statement
}ice IhatheisBlamed PursuanunthePmvitich,i fimCommentsLicenselaw(Chapter9 Sq. Ft. Floor Area Valuation
�FC (commencing with Section 7000)of Division 3 of the B usineas and Professions Coca)or
i yct$ coal he is exempt Ihemlrom and me baso for de alleged exemption.Any violation of
Section 7031.5 by any applicant for a parmil subjects the applicant to a civil Penalty of APN Number Occupancy Type
our more Nan fisc hundred dollars($500).
❑I.as owner of the property.or my employees wish wages a their sole curbpenarion,
will do the work and the structure is not intended or OfferM for sale(Sec.70N.BusiM.. 301 - ROUGH *jgWMWRclions
and Professions Code:The Contractor's Limnse law does me apply m an owner of EEI
pmMny who buildsm improv lhemon,and who doessuch work himselforthrough his 303 - ROUGH MECHANICAL
Own employ.,prodded that such impmnsmmus arena intended orolfered for St.If. 304 - ROUGH ELECTRICAL
however,me building or improvement is sold within oft year of eomplefion,the Owner-
Wilderw0lUKMebumenofpmving thatbedid.1Wildorimpra¢forPurpaaof 505 - FINAL ELECTRICAL
ale.). 507 - FINAL PLUMBING
1,as Owner of Me property,am exclusively contracting wit licensed contractors to
construct the ancient(Sec.7044,Business and professions Code:)the Contractors Lt. 508 - FINAL MECHANICAL
nue Law does not apply to an Owner of property who WJes or improves demon,and
who contracts far such projects with a conmctor s)licensed pursuant to the Contractor's
License law.
1 am exempt under Sec. B&P C for this session
net Date
WORKER'S COMPENSATION DECLARATION
1 hereby eff rte under penalty of perjury one of the following dmhialim s:
I have and will maintain a Cenificam of Consent to Ulf-insum for Worker's Compere
on,u provided for by Section 371)of she labor Code.for the perfoemanm Of de
rk for which this permit is issued.
❑1 have and will maintain Workers Compensation insurance,as sequimd by Section
3700 of the labor Code,far the pertormanee of me w rk fm which this pennil is issued.
eMJJJIyrtAWurkcls Compensation lnsunn ccarzier and Po'ry nWrtper ami (q/
CE TIFICATE OF EK EM MON MOM WORKERS'
T
VVV COMPENSATION INSURANCE
(This section reed"OL becompleted if rhe Permit is fa one hundred dnllam(SIM)
less.)
1 certify coal in the pemGmeeem,of the work for which this permit is issued.I ahtll not
employ any parson in any manner so as to became Saddest to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should
become subject to the Worker's Compensation provisions of the labor CMe,you must
Oforthwith comply with such provisions or this Permit shall be deemed invoked.
Z CONSTRUCTION LENDING AGENCY
'pp h Ihereby affirm that there is a construction lending agency for the performance of
C4> me work for which this p Boit is issued(Sec.3(197.CO.C.)
IJ 0 Lcnticr'1 Name
Id
a Lender's Address
U
Q I certify Net 1 have reed this application and sum that the above information is
W F contact.I agree to comply with all city and county ordinances and stain laws relating to
DUbuilding construction.and hereby avlhorim representalivrs of this city to enter upon the
W .how-mentioned property for inspection purposes.
f-'G (We)agree to ave,indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z APPILICANTCUNDERSTANDSIAND TWILL COMPLY WITH ALL NON-POINT Issued by: Date
'�/f TIC
SOURCE CATIONS. `1
At-roofs If
Sign re of AppI JCae ter Data
HAZA GUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle ha omims,mamB.1
ss defined by the Cupertino Municipal Code.Chapter 9.11.and she Health and Safety
Carle.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed. '
❑Yea lail✓
Will Ihcapplit Tor future buildingoreupanluseequipmentordeviceswhich If a roof is installed without first obtaining an inspection, I agree to remove
it hvardnes oir comeminanm a dcG y the Bay Area Air Quality Management all new materials for inspection.
bia 7
71 Yes
I have mad the maird ours materials requimmcnts under Cbapmr 6.95 of the Califor-
nia Heald&Safety CMM.Semitic,25505.15533 and 15534.1 understand Met if de building
J¢ not currently have a tenant,phot ars my res,exibillly to nowOl�thhs$,sOccupant of the
.egrinmemwichmourc it Porto"ssaaed.f.camncamn,f§[cApancy, ignatureofApplicant Date
•� All roof coverings to be Class "B" or better
0 auomved agent Dam
I
CITY OF CUPERTINO o � 3
FURNACE/AC 7 7
SUPEkTINO PERMIT APPLICATION FORM
APN # 2Z _O 1�— Date:
3�� - l
Building Address: ; I rn `P
-
Owner's Name:
Contractor: ' Phon ,,.Z, icense#: ��S ��—
Contact: Q�I� Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ P mb <ech 12
Job Description A G
Residential / C Commercial ❑
For Residential Installations:
Attic ❑ 151 floor ❑ 2nd floor❑
'kdhere to min set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation PlanningApproval Required ❑
Cost of Project: Type of Construction. Occupancy group•
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Locatio Re lacement ❑
Qty. if
A lic Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A1C 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 Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
/�� 7 7