04040023 CITY OF CUPERTINO `�* s 711nix;I
BLDING DIVISION PERMIT ` CONTRAC 016
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BmLml+cnoDREss: ALLIEDNAIRE SERVICE INC PERMITNo.04040023
T.TT.Y All
OWNER'S NAME: PERMIT ISSUE DATE
SADHAN
ONE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
oo l� O D 0
Y o 0 LICENSED CONTRACTOR'S DECLARATION rc
F 1 hereby from that 1 em licenced under prevision of Chapter 9(commencingJob D
��
Sy wiNSCn,Mm7 )of DiWdc
slon3ol`Mcl1 aan4Pro(cselmu Co ,and my liccna is
^Dy in full c 0. /V 6��j REPLACE FURNACE
3M_ L1CCn ` 23 2004
Lia.p
to D Canua t I - APR
VV ARCHITECTS DE ATION
I understand my plans shell he used u public meonds
joG LicensedPmlcromatl BUILDING
3 OWNER-BUILDER DECLARATION
+� I hemby affirm that 1 em exempt from the Cam✓aclues License Lew for the
O o following mason.(Section 7031.5,Buiness and Professions Cade:Any city or county
$ which requires a permit be convect,alter.improve,demolish,or repair any Common,
=�Sn prior W itsissuance,also roquima the applicant for such Permit in Ne a signed statement
p D that he is licensed pursuant to do Provisions Of INCa
CComcbrsLicenseLaw(Chapter9 Sq.Ft. Floor Area Valuat on
yt`$ (commencing with Section 70DO)a[Division 3 of the Business and Prorceslans Cade)Or
..
,at he is emmpt therefrom and the baser for the alleged exemption.Any violation of rw.nsa-�rs,.,.,.a,
Section 7031.5 by any applicant for a permit subjects the Applicant a civil penalty of 3�V VI3 W3! 'V qCQ Q Occupancy Type
not mare Nan fa hundmd dollars(5500).
❑I,a a..or ofthe Property,or my employees with wages as their sole campeneation.
wtilde the work,and theatmctute is not intended oroBered mrsom(Sec.7W.Business
and Professlona Code:The Contncroes Lirmse,Law dace not apply On an owner of Required Inspections
property who Wilds orimproves the orm.and whodoesiuch m rkhimself or lluough his
own employees,provided that such improvements am notintended oroRered for sale.If.
however,Ne building or improvement is Bold within ane year of.anded tat.the owner
builder will haw the burden of proving Nal W did not build Or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively cenhaming with licensed commission,to
construct the project(Sec.7044,Business and Pmfeaaions Code:)The Contractor's Lb
cense law does not apply On an owner of property who Wilds or improves thereon,and
who contracts for such projects with a conwctar(s)licensed pursuant the Convector's
License Law.
❑I am exempt under Sec. .B k P C frrthis moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRhm under penalty of peejury oro of the following declarations:
I haw and will maintsin a Cortifwm of Consent self-insum for Workers Compete
nation,as
provided for by Section 3700 of the labor Code,for the Performance of the
work for which this permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as requited by Section
3700of Ne Inbar Cade,for the performance of the work for which this permit Is Issued.
MY We CCp��an�s se sure\nc carries end Policyr
Cant a '•`^a' a'a� BCYNO
CERTIFICATE OFEXEMI WORKERS'
COMPENSATION IN CE
(Thu section need notbecompleted ifthe permit is foranc hundred dollas(5100) _
or less.)
1 certify Net in Nc perfumnanec of the work for which this permit is issued.I shall not
employ any person in any manner an as in become subjecl to the Workers'Campensadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.Mar making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you most
�'Z forthwith Comply with such previsions or Nie Permit shall W decond mvokcd.
OCONSTRUCTION LENDING AGENCY
1 hemby affirm Net More Is a construction lending agency for the perfurmance of
C r7 the work for which this permit is issued(Sec.3097,CO,C.)
W QUnder's Name
.a7. z Lcnder's Address
U 0 I certify Nat 1 haw mad this application and etam that the show information Is
W F correct.I agree to comply with all city and county ordinances and state laws relating Or
DU building convection,and hereby auNorim ropresematives of this city to enter upon the
W above-mentioned pmperty for inspection purpores.
(We-)agree to save,indemnify and keep harmless the City of Cupertino against
y Iiabibuu.' ants,col and expenses which may in any way eccmc against mid City
f„)7 in con ueneq�of the
g ting of N' pormit. �f/Ct�2//CIF
s7• APP Ah{y'UNO WILL COMPLY WITH ALL NON-POINT Issued by:S4��k6Ef_ Date
SO CE GUL
c Re-roofs
>Ighnamee of Applic ✓Conmcmr atd
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupantamro orhandle haasrdous materiel
an defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
code,s N❑Yu Nuen zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or
future building Occupant use equipment or dcvima which If a roof is installed without first obtaining an inspection,I agree to remove
LL harerdnus air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection.
District? 1G
❑Yes CINu
the re the har aids mam'als royuimments under C1,m,6.95.f MCC.Iif.r.
I.Heal Seto Code- time] 5,25533 vtJ 25534.1 understand NazirtW Wilding
does n Curren he nam. tesponahillty N notify Ne occupant or the
mgoi rte fch et arta issuan faccrdfcamaa span Signature of Applicant Date
own eathorived seater Dam` All roof coverings to be Class "B"or better
t
Community Development
10300 Torre Avenue
aClOF'
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
1,UPEkTINO
Building De artment .
LL-JOB A DRESS; PERMIT# 0 6 7j�
83 L-L A v�
OWNER'S NAME: A ('lA PHONE #
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 �,'�ya -
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
G Djr
r/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
9UPcEliCTINO PERMIT APPLICATION FORM
APN # 97 Date:
Building Address: W�
Owner's Name: Phone #:
Contrac or: Phone: License #:
„ �� „ `f CT 9 34
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ b ❑ Mech
Job Description: pp
Residential Commercial
For Residential Installations:
Attic ❑ 1" floor 2nd floor❑
dhere to min set back requirement❑
or Commercial Installations:
Replacement s jns:tequ
❑ dditional weight (structural calcs) ❑StructuralCa latiired f anew installationNew instal tion PlA r al Required ❑
Cost of P oject: Type of Constructloef Occupancy gro p'
Strapped n Platform ❑ Bonded ❑I Sq.Ft. Floor Area:
New Location ❑ Replacement 7^
QtY .
A i f le Fee ID Fee Description Fee Group
ENERGY Energy BUILDING
BREty UR 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
PPERMTIFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
8 - '72 . 3