04070190 ' CITY OF CUPERTINO ,:^�' � ✓� n
BUILDING DIVISION PU MIT #COl�tRA ,TQR INTURMATIO
BUILDING ADDRESS: A & H HEATING PERMITN004 O 701.90
F
OWNER'S NAME: PERMITISSUEDATE
Ig 1h JEAN W9'12ANG 770 rT4PLqTMTTT CZT ONE: SANITARYO. CONTROL NO.
(408) 279-0722
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o 0 0 0
YOC LICENSED CONTRACTOR'S DECLARATION
�u
o
lob Description
I thereby affirm that I w licensed under provisions of Chapter 9(commencing
with Sued.7")of Dhawn Sof W 0usiam and Profcuslans Code,and my license is
^ in full force end e0ee7B ADD A/C
�Z License Clw — — Lic.N
i p Deu Con DECLARATION
EC N !.�'Tsy
7W ARCHITECTS DECLARA ON
I uMcrganJ my plgu shall M used u public rmmds
3p, Licensed Poncerional
50 OWNER-BUILDER m me Com ION
I hereby.(firm Net I em eumpt from the Corms Co License c Law for the
p O following mann.(Semite]1131.5.Business and ova.de ons Code:Any city m county
3 p which its requires•permit to enogner eller.Mprow,demolish,or nasi(any tWmen
I,Zapdomitsissuance,alan,tolnea theapplicantof forthe sucCohpermit ctor'sarile aennow Law gned
< thuheucenmd pursuant moire of Diviem of the Contractor's ftwaaw(CMpter9 Sq.Ft.Floor Area Valuanon
(commencingaisxe with arcclfon rem and
of Division f r the
the Business and on.Any ns Crede)of
that he ts exempt thcmfrom and time bash for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 9LTX2AhMer0 0 Occupancy Type
tit mon than Ove hundred dollar ISM
❑ do
red thebrsty, remyempmycu wlthvngexutheh mm eompemness
will d0 Newark,end the he CortimotirLicdede Lawddfmsem(See.70 M,boner of Required Ins ectl0
and Profession,Cade:The Conhmmr'a and
who law dao or apply m an sour of q p
property who ,proar Mp atsuNunn,andwhodaevumhworkheoffeerthrough his
own employceuiprovided th rover impmvemw thin ng year ofcded reoffered IMforower.
however.the buildingor ehn ofpronntissoldwiidnot year of completion,IM owner. _
builds will have Ire widen of pmNng Nn M ale not send or improve for WNue of
ala.), U ( 1
[31.u owner of the property,sm exclusively terminating with licensed conuanon m ,J
aroma the project(Sec.7044.amain of and property
who i Codei The Coram age. red
U.
roue law alma not apply m an owner of mucany who odds or imtrowa Norton,And, IUI
who contracts for both projeeu with a contncto(U licensed pursuant to the Conumtofu
License Law.
❑Ism exempt under See ,Bk PC fm this nems
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby spring under penally of perjury one crow following declarations:
1 hew and will reamutn eCenifinu of Consent m self-Room for Worker's Compere
utlon,u provided for by Section 37011 of the labor Code,for the performance of the
work for which this permit Is issued.
�l'haw and will maintain Worker's Compensation Inwrance,u required by Section
3700 of the Labor Code.for the performance of the work for which thus permit is issued.
My Worker's.C.ompensation Insurance carrier and Policy number me:
Carrier.y{��gI [IO Policy No.:u I Q t0 W 81
CERTIFICATE OF E%EMFrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notweompleud If the permit is foronchundnddollw(SIM)
or Ito.)
I certify that in dmc performance of the work for which this permit is issud,l shall ma
employ any berme in any summer an u m become subject to the Worken'Compenutlon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cedificam of Exemption.you should
become subject m Ne Worker's Compensation provisions of the ubor Code,you mug
,J O forthwith comply with such provision or this permit shall two dccmM revoked.
Z H CONSTRUCTION LENDING AGENCY
H I hereby officethat Nen is construction lending agency for the performance or
Ix> the wart for which this permit ts issued(Sec.309'f,Civ.C.)
W Q lender's Name
W
z Leader',Addmas
IJ Q I certify that 1 have need this application and sou that the show Information is
W coma.l agora to comply with all city and county ordinances and sou laws misting to
O wilding communion,and hereby authorize nprnenutives of thus city m enter upon the
r W above-mentioned property for inspection purposes.
G (We-)egne to save.indemnify and keep humans the City of Cupertino against
Icy Ilabilitin,judgments.costs and expenses which may in Anyway ummc against said City s
U in consequence of the grouting of Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CEREGULATIONS.
�n. 4�..Y/.� ADate � Re-roofs
signa�f r o pf7 pp an camru^tof Deb r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future wilding occurring now or handle hueNous material
as depend by the Comma.Municipal Code Chapter 9.13,and Rise Health and Safety
Idegar
ade.Semon 255330)7 All roofs shall be inspected pr or to any roofing material being installed.
❑Yus No
Will the applicant or future wilding aceupam um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havaranus air cenuminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
uriel]
❑Yns 6'�
IhawmW thehusNmmsmgcriebnqulnnunuunderChapterA95afthcGlifor-
isHalthkSafctyCodo,Sectiau25505,25533aWZ5534.1undcnwmN irdo wilding
not currently have a agent,that It 4 my responsibility m redly the occupant of Ne-
q menuwhichmustbeme missuAnceofa Cerdrmamenc Signature of Applicant Date
r
Owner or authanuAaserl Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
( Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
1,UPEkTINO
Building De autment
JOB ADDRE : PERI*
l0 Z l IM�rZt
OWNER'S N PHO Z
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
r/Contracto igna e \ Date
CITY OF CU13ERTINO p
FURNACE /AC oZ a1 l/
ary of
-UPEkTINO PERMIT APPLICATION FORM
APN ;I Dale:
--- 1038_ _ �� z�Z -off
Building Address:/O/a`t IMPeQL AVE-.
Otaner's Name: � Phone #:�
----Uzi -- - -------
Conuactor: S � G License #:3Ow�•7x
A'
Conoid Phone #:
_�� PK��
Applicant/Contractor'. � ����
e
ildiiig Pert tit Into:
d( Elect Plumb Mechb De ripn .A1sidential: 1.:��i —0/(/ Commercial:
.F or Area: $/Scl.F(.:
Architect/Engineer: Valuati
"Type of Construction: Occupancy Group:
Qt _
A) lice I Fee ID Fec Description Fee Group__
BENERCY _ Ener y BUILIDNG
BRF.MFURN Relocation of Furnace MECHANICAL
_ BREMACOVER A/C Unit > 10,000 cfm MECI IA?:ICAL
BREMAIRHi\N A/C Units <= 10, 000 cfm :MECHANICAL ,
BREMRECEPT Recptl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee: Res BUILIDNG
19 EPERIAI'TFEE Elec Permit Issuance ELECTRICAL
NIPERMITFEE Mech Permit issuance MECHANICAL_
p PPERN[fTFEE Plumbing Permit Issue PLUMBING _
BPERMFIFEE _ Bldg Permit Fees BUILIDNG
_ BPLANC'HK Plan Check Fee 13UILDN'G
__ BUSL[C — Business license BUILIDNG j