05040181 CITY OF CUPERTINO
BUILDING DIVISION PERMIT kCONTk) CGT�OR INFORMATION .
BUILDING ADDRESS PERMIT NO.
VALLEY HEATING & COOLING 05040181
OWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY0. OL NO.
RCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH.
+�+oa LICENSED CONTRACTOR'S DECLARATION N
u I hereby afrvm Nal 1 am licensed under provisions of Chapter 9(commencing Job DCSCrIptloO
W with Section 900117 of Division 3 of NC Bloom and Professions Code.and my license is • � f
R In full force ane ettec��r .�y'�\� 4 • /� J_,
Zq'_ uanae clma_ �L Lic.a INSTALL A/C SYSTEM
nl–ex Daw _� ' ARCHITECTS DECLA ATI N metor „
i�l1 understand my plans shall he used as public records L
oaU
;CG Licensed Professional C Ir ri i7 fl A i" � j�
` g OWNER-BUILDER DECLARATION r
1 hereby affirm Nat I am exempt from Ne Cemracmfs License Law for the
LL
a0 Following reason.(Section
7031.5,Business and Professions Code:Any city or county
K$(L which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance.also MLUIMSthe applicant for such permit to file a signed statement
<
that he is licensed pursuant to the previsions Of the Connector's License Law(Chapter 9 Sq. Ft. Floor Area Valuat on
'Ho (commencing with Section 7")of Division 3 or the Business and Professions Code)or
y
that he is exempt Ikrcfrom and the basis for the alleged exemption.Any violation of
Section 7031.3 by any applicant for a permit subject the applicant to a civil penalty of 3 5VWtf IJ3*el'0 0 Occupancy Type
not mom than five hundred dollars($5007. JFl6`1aCY!`rY
❑1,as owner of the property,or my employees with wages as than in compensation,
Will do to work,and Ne atmclure is not inwnded or offered pursue(See.7044,Business
and Professions Code:The Contractor's License Law does not apply 0 an Owner of Required Inspections
Property who builds or improves thereon,and who does such work himself or through his
own employ=,provided that such improvements are not intended oroRered forande.It.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1.as Owner of the property,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7044,Business and Professions Code:)The Comacwr's Li-
u law docs not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a commotons)licensed pursuant o the Contractor's
License law.
❑1 am exempt under Sec. .B&P C far Nis rcazon
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the following declarations:
I have and will maintain aCertiGeare of Consent to self-insure for WorkersCompen-
utien,az provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Iman¢
ur ,as required by Section
3100 of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insumnc camicrand Policy number rc
Cartier: Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
CITis section need not W completed if the Forbad is for one hundred dollars(SIM)
or loss.)
1 Certify Out in the performance of the work for which this permit is issued,I shall not
employ any Personany manner so a to Wcome subject p the Workers'Compensation
Laws of Califmnia!Dale
Applicant
NOTICE TO APPLICANT:IL after making this CcaificaN of Exemption,you shouW -
become subject to Ne Worker's Compensation provisions of Ne Labor Code,you must
.,Z forthwith comply with such provisions or this permit shall k deemed invoked.
Z O CONSTRUCTION LENDING AGENCY
'ra I hereby affirm that there is a construction lending agency for the performance of
!Yithe,work for which this permit is issued(Sec.3097,Civ.C.)
GA lender's Namc
Z Len deli's Address
U 0 1 mnify that i have read this application and some Nat Ne above ofermadon is
ly — cmem.1 agree to comply with all city and county ordinances and state laws relating to
�U building construction,and hereby authorise repmacrulLzis of Nis city to Cole,upon the
0.i akve-mentioned felinity
For inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tF•t h liabilities.judgments.costs and expenses which may in any way accrue against said City
V z APPCNTUNDER
CSTAgranting
DSthis
LICAAND WI OMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULATI
Re-roofs
Sig to ppli on or Dow/ AZAR OUS MATERIALS DISCLOSURE Type of Roof
Will lk applicant or future building Occup ouslore or handle hazardous mawfial
as'defnedhy the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Ode,secdoazss3z(a7a
❑Yes All roofs shall be inspected prior to any roofing material being installed.
o
Will the a and or future but din Occupant Use equipment Or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
pp w s P yuipmcn
emh hazardous air contaminants as defined by the Bay Area Air Quality Management - all new materials for inspection.
District
❑Yes
In
ave rcaJ the hamNous materials requirements under CM1aprer 6.95 of Ne Califor-
niaHealth&Safely Cale,S -uwa25505.25533and25534.lundersand Nmiftk Wilding
does not eumendy have a tenant Nat it is my responsibility w nodly the occupant or Ne
mquimmentrwhich aftat ri ceofaCenlhcawpfacupargcy. Signature of Applicant Date
owner Oe'a Oriz a t Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
! o Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
UPERTINO
Building Department
JOB ADD,YLESS: � & 77.2 L//i�pGzy e ^-) PERMIT #
OWNER'S NAME: lfliv PHONE # llL ' eG
GENERAL CONTRACTOR: FAX # l c 9c
I am not using any subcontractors: -
Signature Date
Please check applicable subcontractorand com Tete 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
er/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # e �/ Date:
Byilding Address: C�
wds
Owner's Name: U Phone #:
'30P',L e+hv-� q S rJ O�
Contractor: license #:
Von I I jt4 wed6naO 5ziu
Contact: Cupertino Business License #:
\nc)- o,
Building Permit Info. \
Bldg ❑ Elect 2 Plumb Mech [51—
Job
$Job Description:
\YlS'Cot\1 C&VCv,\e<- RIG c,* <
Residential W Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"d floor ❑
® Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Project: /- ,0 Type of Construction: Occupancy group:
Strapped On Platform Bonded LJ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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
J 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 License BUILDING
n,