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BU1LDING DIVISION PERMIT
CONTRACTOR INFORMATION"`
BUILDING ADDRESS:
CONDITIONED AIR'
PERMIT"°' 05090084
OWNER'S NAME:
TTIY WAN('
PERMIT ISSUE DATE
)NE:
SANITARY NO. CONTROL NO.
408 291-2220
ARCHiTECfi'ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
I I licertsed Chapter 9 (commencing
Job Description
Wmby affum Nal am under provisions of
with section roto)of Division3 ofdm Business and Professions Code. and my license is
m fun force and a CC1, Gq� G
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ADD A C ���i
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LA
Liccmc Chis Lk. Y ..11 ' O
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Dam Camncwr
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ARCHffECI'S DECLARATIONQ
I undcmmnd my plans shall v used as public awards
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SEP '29 2005
Licensed Professional
OWNER -BUILDER DECLARATION
I bcahy affirm Nal 1 am exempt from the Cra uacmrs License Law routine,
N I it y
(allowing mason. (Section 7031.5, Business and Pro(esstom Calc Any city or county
Which =qua= a permit In ennsvuct, alter, improv, demolish, or actual any structure
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prior m its issuance. also requirm the applicant for such Permit file a signed statement
Sq. Ft. Floor Area
Valuation
Oat he is licensed pursuant to the provision of the Consracari imus, Law (Chapter 9
(commencing with Section 70!10) of Division 3 of use, Business and Professions Code) or
Nal he a exempt Nemfmm and the basis for this alleged exemption. Any violation of
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Occupancy Type
Section 7031.5 by any applicant fora permh subjects the applicant to a civil penalty of
Out mom Nan Bw hundred dollars (S500k
❑ I." iyanerof Ne Formal, or myemploycea with wagmas Neirmleeompematlon,
Required Inspections '
will do One work, and Neswcurm Is not intended or offered formic (sec. 7136/, Burmass
and Panhassioni Cade: The Conuocuses License law down nut apply to an owner of
pmpeny who builds or improv themon, and wWdoca such work himself orthrough his
own employ=, provided Nat such improvements are not intended at offered for sok. IL
however, the building or impmwmmt is sold within one Sear of complcdon. Ne am.,.
builder will haw Use burden of proving Nat he did not Wild or improve for purpose of
,
salt.).
❑ asownerof the Contracting with:)DueC
Bexclusively
ntractcma U. consumerLathe paned (Sec.
(Sec.Business and
Wi Code:i The Convectors li
n in property who
cane Law docs not apply m an owner of proper( who sectile or improves themon.n, and
who.Larcontracts for such projects with a contractor(s) licensed pursuant m the Convactoh
Licca Law.
❑lam exempt under see. ,B6:PCfor this rtamn
m
Own Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 ham and will maintain a Cenificam of Consent to seif-insure for Workers compere
sation, as provided for by Section 3700 of the labor Cade, for Ne perfortionce of the
work for which Nis permit is issued.
❑ I have and will maintain Workers Compemadon Insurance, as counted by section
37W of she labor Code, for the performance of Ne work for which thio permit is issued.
My Workers ComrxCuSstion Insurance camel and Policy number m:
[j Q!
Carrier: poi O fti \ ( NPolicy No.: 9 99'
GATE
' OFfi EMPI'ION FROM OR Rs'
COMPENSATION INSURANCE
(Thu section need not be completed if the Permit is for one hundred dollars ($1 00)
,if less.)
,
1 certify Out in the performance of are work for which this Permit is issued. l shall nut
employ any person in any manner so as to become subject to the Workcrs' Compensation
Laws of California. Dare
Applicant
NOTICE TO APPLICANT: If, after making Nis Cenificve of Exemption, you should
become subject m the Workers Compensation provisions of the Labor Code, you must
foMwi in comply with such provisions or this Permit shall W deemed revoked.
CONSfRVR10N LENDING AGENCY
1lfar Nat Ncrc is c nn lending agency for the performance of
w ich 01 d (So,.
NC work for which Nis permit is issued (sec. J09'!, Civ. CJ
s
leaders Name
lender's Address
,
.
I certify Nat 1 haw mad this application and sae Nat the above information is
Carmel. 1 agree m comply wit all city and county ordinances and sum laws rtlating m
building convection, and hereby submarine mpresenutives or this city to enter upon the
above-mentioned palmy for imPecdon purposes.
(We) agar m saw. indemnify and keep harmless the City of Cupertino agaian
Iiabilitiu,judgments, casts and expenses which may in any way wcmc against mid City
in consequence of the granting ofthis Permit.
APPLICANT UNDERSTANDS ANQQ--}}VVILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOIJA6� REQ OLUCLATION$: //�
Re -roofs .�
Type of Roof
,(
9 /D�
si,5oal)r,alOfAppranOC}Aanlrfa .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ser future building ..Pa.,,,.. or handle asesur our material
as defined by use Cupenam Municipal Code. Chapter 9.13. and the Health and Safety
zss3z(an //��,,..��
Code. s El Yes
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All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or (uwre Wildingoccupanl use equipment or devices which
it hvardnus air moratorium. as defined by Oc Bay Arca Air Quality Management
all new materials for inspection.
isuict? D.&
f ❑Yes DL{s,s
In aw mad Ne haaardrmsmamrialsmquirtments under Clutter 6.95 of Ne Califor-
,
nu HwalN&Safety Code, Section 25505.25573 wWZsaJa.lumkrsund Nuirtbe Wilding
docs currently haw a ¢nam. Nat it u my Us po ihility w notify IW oesupanl of this
�nmo�s� a
rtqawhich mstt eI .of 10 Mind Ccrtihcate Of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Qwner guth>� a�� Data
•
CITY OF
UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: �\`�� �o<*c�� �c �('
PERMIT #
OSv q
OWNER'S NAME: W
PHONE # 0S - t l 1
GENERAL CONTRACTOR
FAX #
I am not using any subcontractors: 2:) ) J 15 /OS
Signature Date .
Please check applicable subcontractors and complete the following information:
9//3 /oS
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENS #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
X
9//3 /oS
Date
t
0
0
CITY OF CUPERTINO
�" FURNACE/AC
CITY OF
CUPERTINO PERMIT APPLICATION FORM
o.S7 °Cff
APN #
'�G - Sy -COO
Date:
ooi/ 13105
Building Address:
a1\ -Lk `Or. 009aCA'i no Cq GS of y
Owner's Name:
Phone #: C4091
5 UD'c
y1
Contractor: Phone:
License #:
Coni, C -t I
'it -45160 C �o
Contact: Phone:
Cupertino Business License #:
�,<,�a S�lm�
a�33�-I
Building Permit Info:
Seismic Fee Res
Bldg ❑ ElectQ2- Plumb C,.
Mech BC
Job Description: \ �) (a
O
BUILIDNG
Residential Crg, Commercial ❑
Elec Permit Issuance
For Residential Installations:
/ MPERMITFEE
Attic ❑ 1" floott-2^ 2nd floor ❑
MECHANICAL
Adhere to min set back re uiremen
Plumbing Permit Issue
For Commercial Installations:
BPERMFEE
Replacement same weight ❑ Additional weight (structural calcs) ❑
BUILDING
Structural Calculations required for new installation ❑
Plan Check Fee
New installation Planning Approval Required ❑
BUSLIC
Cost of Project: Type of Construction:
Occupancy group:
09.000
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable
Fee ID
Fee Dpgrrintinn
Roa r,
BENERGY
Ener yBUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfrn
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
BUILDING
BUSLIC
Business Licens
BUILDING
vP i - t. I —