03100195 1. CITY OF CUPERTINO' d"
BUILDING DIVISION PERMIT CONTRACTQR'INFORMATIb1Y:'-
C
IBUILDING ADDRESS: J P GORMAN INC PERMITNoQ 3100195
19971 LINDENBROOK LA
OWNER'S NAME: 2880 AIELLO PERMIT ISSUE DATE
Alk HUDNUT F V AND SOPHIE K TRUSTE 10/28/2003
IFINE: (408) 362-9200 SANITARY NO, CONTROL NO.
ARCHITELTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
sit o LICENSED CON-FRACFOR'S DECLARATION
I u� 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Seadc170IN))of Division 3 of NC Basin Pmfeminns Coda,and my license is
± � inmuror, darreet. ({tC I REPLACE FURNACE & DUCT
a Ia License 1 ¢� L¢.p
Dam�ComractorvxA� 2-al
¢¢ CHITECTS DE 1
I a'a 1 under nd my p all ba use]es pts is records
)WU
oy Licensed P c mna
S OWNER-BUILDER DECLARATION
aq 1 he c y affirm that I om exempt from the Contractor's License Law for the
p o mi
following sort(Section]131.5,Business and Professions Code:Any city or county
3 m which requires a pert to Construct,alter,improve,demolish,or repair any structure 11000
prior in its issuance,also on,uires the applicant for such permit to Ne a signed statement
jsa that he is licensed pursuant o the previsions of the Contractor's License Low(Chapter 9 Sq.FL Floor Area Valuation
2t (commencing with Section 7")of Division 3 of the Business and Professions Cnde)ur
�3 3 that he is exempt therefrom and de buffs far the alleged exemption.Any violation of 36923024 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars($500).
❑1,a owner of the pmparty,or my employees with wages as their sole compensation,
will do to work and the shuaure is riminumded orolfered par aala(Sec.7344,Business
and Professions Cade:The Convectors License Law docs not apply to in owner of Required Inspections
property who builds or impmvas thereon,and who dceasuch work himself or through his
own employees,provided that such improvements arc not intended or offered for sale.If,
however,Ne building or impievement is sold within one yeti of completion,the owner-
builder will have the burden of pmving tat he did not build or improve for purpose of
sale.).
El 1,as owner of Ne progeny,am exclusively contracting with licensed contractors to FI N^®
LFII&s
constmct the pmjccl(Sec.7044,Business and Professions Code:)The Contractor's U.
cense Law does not apply to an owner of properly who Wilds or improves thereon,and
who contracts for such projects with a contmctros)licensed pursuant to the Contractor's NOV 2O(g��w{
Y3License Law.
❑I am exempt under Sec. .0 A,P C for this reason
Owner Date _ _ _ B
WORKER'S COMPENSATION DECLARATION BUILDING��/ING
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Ceni Genre of Consent to self-insum for Workers Compen-
sa,ion,uprovided for by Section 37W of Ne Labor Code,for the performance of Na
work for which this permit is Issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
]]rut of the Labor Cade,for Ne performance of the work for which this refit is issue].
tyy Worker's Compensation l�t¢u nm camcr end Policy number am:
Carrier. < < SPo' No.M 36013 6
CERT •ICATEOFx %Eli rare
WORKERS'
COMPENSATION INSURANCE
(This section need nm be completed Rthe Fermi,is for one hundred dollars($RX))
ass.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compcmatiort _
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Com pcualion provisions of the Lester Coca,you must
�,Z forthwith comply with such provisions or this Permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a construction lending agency for the performance of
Y, a7 the work for which this peril is issued(Sec.3097,Civ.C.)
QLenders Name
z Lender's Address
;J Q I minify dat 1 have mad this application and suite that the above information is
Fcorrect.I agree to comply with all city and county ordinances and stale laws relating to
�U building Constriction,and hereby authorise mpreuntativu of this city to enter upon de
N G above-mentioned property for inspection purposes.
(We)agree 1n¢ave.Indemnify and keep harlCM the City of Cuper,inn agalnal
tiN Iimbiluies.judgments.nems and carouses which may in any way acme against said City
UZ in conical nm of the granting of this permit.
^' APPLICA UNOE STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE EGUL ONS.
Re-roofs
S ore (App c UContraaor J Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill the applicant or future building Occupant store or handle hrrsrdous material
a di cd by the Cupenino Municipal,Code,Chapter 9.12,and the Health and Safety
n obas oe 25532(a)?)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or r umabuildfng occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air comaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
I have mad de hax.oha materials requirements under Chaptcrb.95 ofde Califor-
.is Hcaldffi Safety Ces,Sections 255(15,]5533 and 25534.1 understand thallf the building
does not currently have a tenant,that i,is my responsibility to Lolly the Occupant of da
rc u'mmcn which must tprinrmissuanccofaccmrxaam of Occupan y. Signature of Applicant Date
owner merived gen l6D All roof coverings to be Class "B" or better
CITY OF CUPERTINO 0�3/ b
]FURNACE/AC
• CUPEkTINO PERMIT APPLICATION FORM
APN# Z7 Date: 6
Building Address: ✓ (
koA-►1 Lin
Owner's Name: Phone#:
F'. qbS , 9q�. 3 sty
Contractor: License#:
65 r mo-rl unr✓- Sn-v ira 6630
Contact: Cupertino Business License#:
7Z:�;2 Ga,-rna-r-
Building Permit Info:
4 '
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description: Q
fV o0ti4 "r
Residential I Commercial ❑
For Residential Installations:
Attic ❑ I' 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 insta at n Planning ApZroval Required \,
Cost of Type of Cons do Occupancy grou r 2;
Strapped On Platform Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Apph ble 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 Rcc tl, Switch&Outlets ELECTRICAL
I 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
BU IC Business License BUILDING
1