04080166 5 CITY OF CUPERTINOpuru � •�' • ' "�' %'� "`
BUILDING DIVISION PERMITCONTRAC�TORYINFORMATION
BuaolNGnooRFss: A PERFECT CLIMATE PEaMIrND.04080166
OWNER'S NAME: PERMITISSUEDATE
ONE: SANITARYN ONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT' PLUMB MECH
0 I9 E
ao"' LICENSED CONTRACTOR'S DECLARATION
mp I be�,by arOrm mai I am limamd under provisions of Chapter 9(commencing
lob Description
W withst. %Knot Oiv'xion3ofthc Busirmaand Prof um Cadc,andmyliccnmis
e
in eanderrect. ZO 'i S REPLACE FURNACE & ADD A/C
LicenanC Lae
t;,p Dan: Co.,
u.q uJ c A CHITECTS DECLA N
d h!JA�nderstand my plans shall he used as public me
JyU ' `Y
3 G Licensed professional '
OWNER-BUILDER DECLARATION
vt
y I hereby affirm that l am exempt from the Contractor's License Law far the
cc following mason.(Section 7031.5,Business and professions Code:Any city or county
K m which requires a permit to construct.aper,improve,demolish,or repair any structure
m_y prior to its issuance.also requires the applicantfor such permit to File a signed stamment
�z< that w is licensed pursuant to the pmvisiotnof the Contractor's Been.law(Chapter 9 Sq.Ft.Floor Area Valuation
tete (commencing with Section 700))of Division J of the Business and Promosions Cods)or
i $ that he is exempt therermm and on,basis for de alleged exchri Any violation of
Section?031.5 by any applicant for a permit objects the aIpplicanuo a civil penalty Of 3SEN WOMW 00 Occupancy Type
not mom than Eve hundred dollars($500).
❑I,ssowner o(the progeny,or my employes wire waguss thep sole eompewJon,
will do the work.and the sesame is not intended orofrerw for side(Sm.7044,Business Required Inspections
and Professions Codc:The Contractor's Liana Law dont not apply to an owener of q p
property who buildsorimprovas demon.and whodoes such work himself ter through his
own employers,provided that such improvements art not intended croRend f ersale.IL
however,she wilding or Improvement is sold wiNin one year of oomphation.Ne owner.
wilder will have me burden of proving that h.did not wild Or improve for impose,of
sale)
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.9044,Business and Professions Code:)The CommetorE U.
cerise law dors not apply to an owner of property who wilds or improves dtemon.and
who ep.,nets for such projects with a eonuactm(s)licensed pursuant to dta Conuactoh
License Law.
1 am exempt under Sec. ,B&P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby alTrm under para ty of perjury one of des following dedarmions:
1 have and will maintain aCenificam of Cement to self-insum for Worker's Compcn-
ion,as provided for by Section 3]00 of thee Code.for the performance of the
7037W
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u requiredby Section
of the labor Code,for the performance of the work forwhich this permit is issued.
y Workers Our l''n�s�^attr(Ince ca�rrri/erraandcaP/o9liic n�u/r-py�b-c(r�-a(r-J�4's� Or
`� ' (C IFICATE OF E%EM Ff10MW TUM S'COMPENSATION INSURANCE
(This section need not w completed if the permit is for one hundred dollars(SIM)
is,lass
I certify that in the performance of the work for which this permit is bound.l shall not
employ any person in any manncri n as m become mbject to thc Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL atter making this Certificate of Exemption,you should
Whom subject to use Worker's Compensation provisions of the laMn Code,you mum
.J O forthwith comply,wm
with such provisiu of Nis permit shall w mrewired.
oked.
'Z 5; CONSfRUC ION LENDING AGENCY
'e. I herby affirm mat then is a construction lending agency for the performance of
!Y > the work for which this permit is mued(Sec.3091,Civ.C.)
Lendher's Name,
d '$A
.7 Z I� dd.,..
U Q 1 cenify mat I have read this application and show that me shove ormmation is
Iy f" correct,)agree to comply with all city and county ordinances and state laws minting to
O V building construction.and hereby autl representatives of this city to enter upon thc
W loam-mentimred progeny,for inspection on,Oms.
(~ 1 (We)agree to rove.indemnify and keep harmless the City of Cupertino against
N
liabilities,judgments.costs and exmoscs which may in any way accrue against said City
U Z in consequence of the granting of this permit.
^ APPLICA R UNDERSTANDS AND WILL COMALL N� NT Issued by: Date
SOU ATI S.
Sill c of plicamiCon motor 'Dam— Re-roofs
HAZARDOUS MATERIALSIL IS SURE Type of Roof
Will the applies.,or(mum wilding occuyam or,or handl.havamom material
as defined by the Cups nine,Municipal Codc.Chapter 9.12.and the Health and Safety
Ode Section 25532(a)7eftum
) All roofs shall be inspected prior to any roofing material being installed.
Yea
Will me appEcawilding occupant=equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
:mithmardnmaircon defined by use Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycs
1 have mail Ne hwaW mawrialemquiwmcnho under Chapter 6.95Oldie Caliper-
not Health&SafelyCode.Sections 25505.25533 and 25534.1 udcrmand Out,ifthc wilding
dors not currently ham s tenant that it is my respomibility ro notify the acupant of the
royviw nhowni m mntpnnrtoima nncenifigtenra..pan.: Signature of Applicant Date
Owner ora dagent Da 0 All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
' ✓` Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: , h �l r PERMIT #
V U ll
OWNER'S NAME: PHONE # Z --
GENERAL CONTRACTOR: i FAX #
I am not using any subcontractors:
Signature Da e
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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
\ I
Owner/Contractor Signature D to
-� CITY OF CUPERTINO
fl Lj P,1N AC E/A CCITY OF
UPEkTINO PERMIT APPLICATION FORM
APN # /� Date:
Building Address: i 0 � �J
t 1"
Owner's Name: Phone #:
2 -$
Contractor: . Phone: , License #•
,.Wil- --72315z6'
Contact: Phone: Cupertino Business License #:
Building Permit In o:
Bldg ❑ ElectuD/ Plumb ❑ Mech <LJ�
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor ❑
Adhere to min setback requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Pe lacement ❑
Qty. if
App4able 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
BSE'ISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
i BPERMFEE Bldg Penvit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING