04060214 r CCI'Y OP'CUI'fsR'I'INO a„ �. r
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIOt„N
Bml.Dwr,ADDRESS:11220 T-A TOLLA 21 AAA sFURNACE & AIR CONDITIO 'qN(b4060214
OWNER'S NAME: PERMIT LSSUE GATE
STANLEY R BRT
ONE:
SANITARY NO, CONTROL NO,
(408) 293-4717
ARCNITECi/BNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Opp LICENSED CONTRACTOR'S DECLARATION 0
U E 1 hcrchy affrm that i em licen.Ud antler provisions of Chapter Y(commencing Job Description
•n�m wiR Section 700(dof Division 3 of the B mo.and Frofesvidre Codc,end cry become is I�II���tl �D
�• in full force and effect. TIL ll }a
3'q4LicenseClaa Lie.. REPLACE HEATING & A/C SYSTEM
w Dam GdnDEC JUL 2 2004
ARCHO ECr5 0ECLARATION
Biu l understand my plans shall he used as public records
;oG Lacnuu Pmfcsvanal �D�u��
OWNER-BUILDER DECLARATION
3 0 1 hcrchy.(firm that I am exempt from the Contractor's C's License Law lit(the
a o following rias;ferritin](131.5.Business and tie,demolish,
Code:Any city Or .only
$� which requires;a permit w construe,al¢q improve,demolish,nr repair any structure
Fi< pdormitsiauance.alsomquires the applicant for such permino f le a signed statement
that he is licensed pursuanun Ne provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
$ (commencing with Section]( R(if Division 3 of the Business and Professions Code)or
that he is exempt thetetrom end the basis for Ne alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects Ne applicant t...ivil penalty of
not more than five hundred dollars(SSW). 3 e100 Occupancy Type
0 I,as owner of the progeny,m my employees with we,as Nch sole compeneuion,
will do Ne work,and Ne structure is oat intended or offered for sale(Sec.7 a .Business
end Professions Code:The CommctOYs Latest,Lav,does net apply to,a owner of Required Inspections
property who builds or improses Hereon,and who docsauch work himself or through his
own employees,Provided that such impmvemente arc not intended moRered for sale,If,
however,the building Or improvement is sold within Otte year of camplimm,the owner-
builder will have the burden of proving Nat he did net build or improve for purpose of
sale.).
1,a Owner of Ne progeny,em exclusively contracting with licensed convectors to
Cn'a.- the'-jeer(Sec.]BW,Business and Praf esions Coded The Contractor's U
cense law does not apply m an owner o(prupeny who builds or improves thereon,and
who contracts for such Itmjem with a cnntraeor(s)licensed pursuant m the Contractors
License Law.
O l am exempt under Sec. ������� / B a P C for this mann
/�. f+'--��'�—Date
WORT R'S COMPENSATION DEC RATION
Ow p hereby affirm urpenelly of perjury one of the followgdeolaretions:
I hahave and will maintain a Ceni dime of Consent 0 Ulf.insum for Wm@rs Compere
anion,a Provided for by Section 3700 of the Labor Code,(Or Ne performance Of the
work for which this'emit is issued.
0 1 have and will maintain Worker's Compensation Insurance•u required by Section
37W of Ne Labor Code,for the performance of Ne work for which this permit is iaued.
My Workers Compensation Insurance artier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' +
COMPENSATION INSURANCE
in section need not Ifo completed if the Permit is lin one hundred dollars(EI W)
Orlos.)(Th
1 certify Nat in the performance Of the work for which this permit is issued,I shall not
employ any person in any mannersn as to become subject to(be Wmkers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this Cenifcam of Exemption,you should
become mhjeet to the Workers Compensation Provisions of the labor Code,you must
z forthwith comply with such Prnvidons or this Permit shall he deemed revoked.
OCONSTRUCTION LENDING AGENCY
1 hereby affirm chat from is a consweind lending agency(or the Performance of
(. me work for which this Permit is iaved(Sec.3097,Civ,C.)
25 Lender's Name
3 z Lender's Address
Q 1 certify Nat 1 have rad this application and sure Thu the above immmuiun is
Fcorrect.1 agree to cumply with all city and county ordinances and state laws relating to
V buil ingconswctinn,and he achy acidomire remercnmiva of Nis city to ewer upon the
W almvn as,judned pmPc costs
for expccuon purposes.
px (We)agree to save,indemnify and keep hurmlca dte City Of Cupertino against
Z iu bit consequence
of rs,the costs end apenses which may in anyway accmc against said City
) ,z A APPLICANT
of UNDERSTANDS
S A permit.
'-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATI�,"s/
s arerrApphnvcont�em Z Re-roofs
a
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store Or handle hazardous material
a tleffned by the Cupertino Municipal Code.Chapter 9.12.and the Hl and Safety
Clue,Secuon 8532(.)?
El Yes ANo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or from building occupant me equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit haraNOus air contaminants as dcfned by the Bay Area Air Quality Management all new materials for inspection.
Di ries?
s' 0 Ycs �(No
1 have read Ne hairdo t,materials reyvimumnu under Chapter 6.95 of the Callfoo-
nip Health a Safety Cade,sections 15505,25533 and 85151 undersand Thar if me(wilding
daps nm oammly haat a tenant.Nat it is my responsibility to rami I the occupant of Ne
requiremena chm t met prior to issuance of a Certs fiate of Occupancy.
Signature ofApplicant Dale
Ow ,,or morcollx.mort 11 Dam All roof coverings to be Class"B”or better
/ CITY OF CUPERTINO
FURNACE/ACv Z/
� CITY OF
PEI�TINO PERMIT APPLICATION FORM
APN # / Date:
2y 200
Building Address:
//220 /-A /au Cvur�
Owner's Name: Phone #:
STY ✓LEY 2U� Z53--5-14-17
Contractor: Phone: License #:
��A U�uRtE �'G DBJ 201J=�z7/7 Ito Pell
Contact: Phone: Cupertino Business License #:
Cf//his 2.f3- 4Z7/7
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech L`t
Job Description:
Residential Commercial ❑
For Residential Inst llations:
Attic ❑ 1" floor M 2"a floor❑
dhere to min set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structur'al�alculatiyy� quired for new installation ❑
ew installation Plannl g A rova] Required ❑
ost of Project: Type of Construction: Occu gr-ott /
Doo 57�tA2D
Strapped ❑ Platform ❑ Bonded ❑ Sq.Ft. loor Ar
New Location ❑ Re lacerrient ❑
Zty. if
i cable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAiRHAN A/C 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 A / _ BUILDING
BUSLIC Business License 7� BUILDING
G J