03050003 77
CITY OF CUPERTINO �="°
t BUILDING DIVISION PERMIT CONTRACTORTN�'ORMA'CTON .: .
9k�a2nxb.2: X*eYS: `�%"ss�°xa b�i kzs d]tiU,<SHbr 5" ,
�VnATffWIN LA PAYNE HTG A/C PERMITNO
'S`IAT9ATRICIA A 2045 STONE AVE PERh1"L$ff7bl/2003
NE' (408) 294-89S7 SANRARY NO. CONTROL N0,
ARCHITECDENGTNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
_00 LICENSED CONTRACTOR'S DECLARATION
mC I wmby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
with Section] ) t)ivision3of the Busi and Prof.,.Cade.andmYlicenseu
rmtem act. �,J�'9� ADD A/C TO 220V ELECTRICAL t� tIV6a`sA
�y�z L'ccna Cl —lo—C 20"L;2
Zgo DW4'T-( Cenuat - MAY 8 2003
R
ARCHITECTS D LARA ION
2 1 understand my plana shill he used as public records
�taU
;LLl Licensed Professional BUILDING
C) OWNER-BUILDER DECLARATION
.�<z 1 hereby affirm that 1 em exempt frem the ConlracmYs Uccnse Law for the
F.00 following mason.(Secumn BD 1.5,Business and Profesions Code:Any city or county
g Pi which requires a Permit to conedo,t,alter,improve,demolish,or repair any structure
Fly prior to its issuance.also inquires the applicant for such Permit to file a signed statement
fsi]
Out bc islicented pursuant to the prevision of the Commuctur's License Law(Chapter 9 Sq.Ft. Floor Area $3'V-�4tion
z 1-$ (commencing with Section 700o)ofDivision 3 of the Business and Profnaion Code)or
_ that he is exempt therefrom and the back;for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of 3 gtepQ.1II� erO 0 Occupancy
not mere them
five hundred dollars($!100). P Y Type
❑I,a owner of the property,or my employes with wages az their sole compensation.
will do the work and the swnure is not intended or offered for We(Sec.7041,Business ,pT,i 7lufp S iv7
and Pmfessiona Code:The Contractors License Law don not apply he m owncr of f(e�i�'Htre61TIS CtlO ns
progeny who builds or improves thereon,and who doessuchwork himselforthrough his 303 - ROUGH M CHANI AL
own employees.provided thatsuch improvements art not intended droll for safe.If. 3O4 — ROUGH ELECTRICAL
however.the wilding or improvement u cold within one year of completion,the owncr-
builder will have the burden of proving mat hte
e did am wild ar improve r mrpro a of 505 — FINAL ELECTRICAL
:ala.).
❑I,as owner of the pmpcny,am exclusively convening with licensed centrecmrs to 507 — FINAL PLUMBING
construct the pmjm(Sec.7044.Business and Professions Cade:)The Contractor's Li- 508 — FINAL MECHANICAL
cone law docs not apply a an owner of property who wilds or improves themon,and
who contracts for such projects with a conusetor(s)licensed pursuant to the Contractor's
L'erne Law.
r am exempt uMer Sec. .B k P C for this mason
Owner' Dem
WORKER'S COMPENSATION DECLARATION
1 bemby absent under penalty of perjury can of the following deciaradonc
I haw and will maintain a Cenilicam of Consent self-insum for Wo laces Compen-
Wkm.az provided for by Section 3700 of the laver Code.for the part... a of the
wok for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,az required by Section
3710 of me labor Code,for On
Performa a work for which this permit is issued
My W kers Compensation insurance a Policy number art:
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need nut be completed if the permit is fororc hundred dollars($100)
or less)
I certify that in me performance of the work for which this Permit is issued,I shall not
employany my rseaz Ibbpfjamma subject to ftWorkeri Comn
pcauon
laws of C o n.Da¢ ispSof,
Apel' �1 c` �
Ofl APPLICAM:If,after caskindAiS Ccnificam of Exemption,you should
been feel to me Worker's Compensation provisions of the Tabor Code,you most
O forthwith comply with such provision ser this permit shall W dccmed revoked. .
Z rA CONSrRUCTION LENDING AGENCY
[-. I hereby affirm that there is a convection lending agency for the performance of
a h7 the work fur which this permit Is issued(Sec.3097,Civ.C.)
QTender's Name
J z renders Address
U O 1 ceniry that I have read this application and sum mat the above information is
Ire. F' e-rect.I agree to comply with all city and county oNlnmces and sac laws mining to
OU wilding convection.and hereby enhance representatives of thiscity to enter upon the
ahovcmenuonWpropertyst for and
exiseuen puryexs
FF-t ftinc against
h inconsequene of Oc astsand ex penes which ren mnify and keep faceless
way seen aty of gmnst said City
V z in conegtrercc of me granting of this permit.
^ APPLICANT UNDERSTANDS AND Wt1,I COMPLY ALL NON-POINT Issued by: Date
SOURSEREGULATI S. k/ /
-I-p Re-roofs
V I _
ol gnvurt of AWlicaml tractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Oc applicant or future building occupant store or handle hmardous material
m defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Semon 25532(y' All roofs shall be inspected prior to an roofing material beim
❑fin �Ne P P Y g g installed.
Will the applicant ter future building mcupani use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardous air contaminants az defined by the Bay Area Air Gustily Management all new materials for inspection.
District?
❑Ycs
1 have mad the havardous materials requirements under Chapter 6.95 ofthe Califor.
an.Halm d:Sefely Code,Section ZM5,25533 anal 255M.I undersad that if dhe wilding
docs not currently haw a unml WI i ' my sponibility m ratify the occupant or me
vire fts which must matpus misses cofa Ccnit ter Occnpaney. Date
n. \ .S--) -03 Signature of Applicant
Owner or aethoriacd agcnP Dare All roof coverings to be Class "B"or better
n
CITY OF CUPERTINO
IlIl d' FURNACE/AC o3 � r` --o63
CUPEkTINO PERMIT APPLICATION FORM
APN # /„ /� Date:
Building Address:
7fa03 tGtCL�,J �N Co�ieT
Owner's Name: Phone#: i
PATT ZSS ^ 37-'L,4
Contractor: License #:
uUoC-
Contact: Cupertino Business License #:
n-e-
Building Permit Info:
Bldg ❑ Elect Plu 'b /
Job Description:
Residential ® Commercial ❑
For Residential Installations:
Attic ❑ 1" 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:
SlllGli= r�� �
Strapped ❑ On Platfo ❑ { Bonded LiSq.Ft. Floor Area:
New Location ❑ Re lacementl�"'
ty. if
plicablc Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIKHAN A/C Units <= 10,-600 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE 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