03060034 D CITY OF CUPERTINO
BUILDING DIVISION PERMIT GQNTRAGTQR INk'ORMATION
f BUILDING ADDRESS: A & H HEATING PEaMITN003060034
10801 JOHNSON AVE .
WNER'SNAME: 770 CHESTNUT ST PERMIT Lq'GP&Y!E4/2003
HARLES CALDWELL
NE (408) 279-0722 SANITARY NO. CONTROL NO.
ARCHTDICDFNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB IMECH
0 0 0
uo0 LICENSED CONTRACTOR'S DECLARATION JbDescri vers
�+F I herebaffi
y affirm Nal mo
al I am licensed under provisions of Chapter 9(co
mencing I3
�y wlN Sectio''")of Division 3 of Ne Business robe Professions Code,and my licenx is
�„ in imuccl ndern J 64y FURNACE REPLACEMENT
jg? License ClaA Lk.g FUNALE9 J
F p Da¢ > Cmvumr.
DECLARATION
-+� tit
I uMerstsn N
nJ my plaall be used as public ranNs
3r to� Licensed Professional JUN 2 3 2003
OWNER-BUILDER DECLARATION
i f 1 berthy,air,.that I me exempt from she Convector's License Law for the - BUILDING p�/�
DO following reason.(Section 7031.5,Business and Professions Code:Any city or county IC7�JILIJIIVL7t
which requires•permit to conmruct,abcr,minnow.demolish.m mpsir my awctort
y prior to its issuance.also requires(be applicant for such permit m file a signed summent
shat M is licensed pursuant to the provision of to Convenor's Lice•ce Lew(Chapter 9 Sq.Ft. Floor Area 2` aWtion
ic�$ (comers neingwiNS cdon70DMotUvuion3oflbe Business andPr rmlom Ca )or
u esempt Ihmfrom and the basis for IM alleged a ortmon.My violation of
Section 7031.5 by any applicant for a pemtit subjects the applicant m a civil penalty of
not more then foe hundred dollars($500L er Occupancy Type
❑1,las owner of Ibe property,or my uoployces wise wage as Nei to compensation,
will do the work,and um structure is not intended orof1red hostile(Sec.7044,Business gty�w,nmaa
and Professions Code:TM Comactufs license Law docs rot apply m as owner of 303 — ROUGH AlfR� dons
property who Wilds in improves thercon,and whodeessuchwerkhimselfor through his 304 - ROUGH ELECTRICAL
own employcet.provided vat such improvements are not intended eroRered foraale.If.
however.the Wilding or improwinem is sold within one year ofmmpletion.the owner- 505 — FINAL ELECTRICAL
Wieder,will have the When of Proving that M did am Wild or improw for purpose of 507 — FINAL PLUMBING
El I,as owner of see property,am exclusively contracting with licensed contractors to 508 - FINAL MECHANICAL
construct see project(Sec.7044.Business and Professions Code:)TM Contractor's Li-
cense taw dors not apply to an owner of property,who Wilds or improves thereon,and
who contracts for such projects wish acomracmr(s)licensed pursuant in sec Cmtractots
Liccns Law.
0 Iamaaemplunder See .Bk PCfmuiamamn
ner Data
WORKERS COMPENSATION DECLARATION
I hereby surrm under penalty of perjury one of the following dreiantions:
I haw and will maintain a Cerdfiateof Coruent toself-insure for Worker'sCnmpen-
7[371M
on,u provided for by Section 37011 of In Labor Cade,for the performance of the
k for which this permit is issued.
1 hats and will maintain Worker's Compensation Insurance,as requited by Section
of she labor Code,for see performoce of see work far which his Resit is issued.
Workce,Compensadon Imuranee artier andPo linuort are:rtier._m1,�CJI I HJ y Policy Nd�ItL `
CERTIFIC OMPE TIONI NFAO WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if see permit Is forms,hundred dollars(SIM)
or less)
I cenify,that in thee Performance of the work for which this permit is issued,I shell not
employ any person in any moncrm as to become subject to sec Workers'Compensation
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making his Cenifca c of Exemption,you should
become subject in the Worker's Compensation provisions or the lahsa Cnde,you mum
.J O foMwiu comply with Rich dm
Rich provisions or this Permit shall be, eeed rooked.
Z y CONSTRUCTION LENDING AGENCY `
(—' IMreby afRm that then is a conservation lending agency for the perromuree of
fY.moi
ft work for which this pencil is issued(Sec.31197,Civ.C.)
W Under's Name
0. Under's Address
�;) z
U Q I..try hat I haw read his application end sum un sec mw infom limn is
W F coaccL I agree m comply with all city and county ordinances and auta laws relating to
OU Wilding cmmrvcdon,and hembymmodoe rtprescnmiws of this city in enter upon or
w shove-mentioned property for impaction purposes.
gL (We)agree to saw,indemnify and keep hamlcss the City of Cupertino against
Ln liabilities.judgments.cleats and experpea which may In my way accrue against and City \
U z in cm seq serx.of the,gramm,of this Pemil-
t—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
a�AG��4Re-roofs
Stgn of ADphcovConvacmr am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Use applicant or future Wilding occupant store or handle hau dons material
all u delved by the Cupertino Municipal Cade,Chapter 9.12.and see Health and Safety
section us32(a)7
❑res 0Ao All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haArdous air conuminanu u defined by see Bay Ata Air Quality Management all new materials for inspection.
Districil /
❑Yen 0
[haw read the hvasdtms mnerials roquirtmcnu undcrCMpkrti95 of sec Califor-
nia Health A Safety Code.Secdom 25505,25533 od 2 53.1 nolersmnd Nat if Ur.Wilding
does not currently haw a tool that it is my rapoombility,m notify do nnvpot of ft
myui entawhkbmum4tpe�� �r,c`n;E"emj'°""p
Signa ture of Applicant Date
Owner arauhmri7¢d.,car" D,m All roof coverings to be Class "E"or better
�� CITY OF CUPERTINO 03 b
s FURNACE /AC
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
375- 31 - o6. - -�
Building Address:/ ' .1�ks
�gO A000
Owner's Name: Phone #:
qq
Contractor: t IT rL r /� �
Contact: G � License
r G l sC2-)q
7 Phone #: p7
9- aa.
Appl icant/Contractor:
' niI6 G
Building Permit Info:
Bld Elect Plumb Mech
Job Description: >
Residential: �L(Zvt9t �(,(� Z(�l. C�LtZeti1�l� mercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY - Energy BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfmMECIiAN1CAL
BREMAIRHAN 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
PPERMITFEE Plumbin Permit Issue PLUi�IB1NG
BPERMFEE
Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
7 33