04040115 CITY OF CUPERTINC,
BUILDING DIVISION PERMIT m,CONTRAGTORINVORMAT ON. x'
BUILDING ADDRESS: SPECIALIZED HEATING & AIR fM5NO04040115
OWNER'S NAME: PERMIT ISSUE DATE
Igh JOHN JAMES 8749 N 2004
ONE:: SANITARY N0, CONTROL NO.
(510) 886-5853
ARCHITECIENGINCERt BUILDING PERMIT INTO
BLDG ELECT' PLUMB MECH
0 0 0 0
10, LICENord CONTRACTOR'S DECLARATION
e hcrehy off rte that,I am licensed under provisions or Chapter 9(commencing Job Description
¢� with Scmio 7(1f10)nrpivision3af the Busincs. Profcssiuns Code,and myliccnsc is
eLly mf derree REPLACE FURNACE & ADD A/C ����
;qz Dee elaaa Lic.M 20 CIRCUIT & PVC DRAIN/VENTP
Data Chmronor
G'y A HITECTS DEC
5 W U I understand my plans shall he matins public records
a. APR ` ' 2004
Gy Licensed Promasummi
OWNER-BUILDER DECLARATION
a I botchy affirm that I am exempt from the Contractor's License Law for the BUILDING.�
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county ■q g,IYYI
e m which requires a permit to construct,aper,improve,demolish,or repair any svucame
Poorto it,issuance.also requires the applicant for such permit m file..,gmed statement
pSp that he is licensed pursuant to the provisions of NC Contractor's Liverno Lew(Chapr,9 - Sq. Ft. Floor Area Valuat, kpg00-
xt-0 (commenting with Section 7")of Division of the Business and Professions CSWe)or
9 that he is exempt themfrom and Ne basis for Ne alleged exemption.Any=of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally,of ane ApN Number Occupancy not mom Man five hundred dollars(5500). p y Type
01,as owner ofthe properly,or my employees with wages az their sole compensation, 35624019 . 00
will do the work,and the structum is not intended or offered for sale(See.704.Business
and Professions Code:The Contractor's License Law does not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,Ne building or improvement is sold within one year of completion,the owncn
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 convectors to
eonswet the project(Sec.7044,Business and Professions Cotler)The Convector's Li.
cense Law does not apply to an owner of properly who Md Ids or improve Menton,and
Who contracts for such projects with a commemr(s)licensed pursuant to me Contractors
License Law.
❑I am exempt under Sec. ,B&P C far this rcazon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby afore under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker'sCumpcn-
,alion,as novided for by Saturn 3700 of the Labor Code,for me perfmmonce of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of Me Labor Code,for me performance of Me work for which this permit is issued.
My mkers Com ensatinn lnsumnce artier and Policy num rate:
cr:5 E _Policy N 1 7<<
CERT rICATEOEXEMPr10N FROM
KERS'
COMPENSATION INSURA E
Mis section need not be completed ifthe Tamil is for one hundred dollars(II00)
or less.)
1 cenify that in The performance or the work for which this permit is issued,1 shall not
employ any person in any manner set az ar become subject to the Workers Compcnsation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should
become subject to the Workers Compensation provisions of the Lebo Code,you must
.JO
Eforthwith comply with such provisions or this permit shall he deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a coevuction lending agency lot the performance of
7 me work forwhich this permit is issued(Sec.3097,Civ.C.)
W�Q Lender's Name
Z)
z Lender's Address
U Q 1 corify Mel l have read This application and swim that the above information is
ILt t"' correct.I agree to comply with all city and county coli minces and state laws relating to
V building construction,and he reby amhorim represcntativos of this ei ty to enter upon the
above-mentioned property,for inspection purposes.
H y
We)agree to rove,indemnify this and keep harmless the City of Cupertino against 1 V
N liabilities,judgments costa and expenses which may in any way seems against said City
V z A APPLICANT
of Mc UNDERSTANDS
of this permit.
^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULA S.
Re-roofs
ig tura nrnprd anocimmemr
11AZARDOUS MATERIALS DISCLOSURE ✓ Type Of Roof
Will Me applicant ser future building occupant atom or handle havarmus material
az denncd by The Coconino Manuel pal Code,Chapter 9.12,and the Health and Safety
.1111iode,Section 255]2(¢)?
❑vee � All roofs shall be inspected prior to any roofing material being installed.
wili me""d m Or
mmm building«capant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit'IaxaNnus airconamimmus as defined by the Bay Arca Air Quality Management all new materials for inspection.
Terrier? _
❑Yes Llrvn
1 have mad me haraNnus materials myviremenu under Chapter 6.95 of the Califon
DictHelm&Sarcty Code SmammO 5505,25533 antl25534.1 undersand thmifmc building
does not atonally have a tenant,Met it is my responsibility m nosily the ocuponl of me
rcquicrom which mu melpnor .asaanepnToCertlfcian.1Occupancy. Signature of Applicant Date
^! All roof coverings to be Class"B"or better
or
ser authori.ar are Data
Community Development
aClOF'
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
,SUPEI�TINO
Building Department
JOB ADDREWP PERMIT#�j P
2.1� a QknA ,� f
OWNER'S N '7$j ey,,e $ PMNE z�(o -0280
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
eating S c-
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Pr/Contractor Signature Date
CITY OF CUPERTINO
� �' FURNACE/AC o
SUPEIOF
TY
RTINO PERMIT APPLICATION FORM
APN # Date:
S � 2 Ol — 1 , p
Building Address:
2 6L v\.
Owner's Name: Phone#:
n v e 9b`6 72 - p 2�`ZJ
Contractor: Phone: License#:
S eu 510 B�sC �5BS3 7y(7k�
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech l�
Job Description:
re g c r r L q-,2-o r t r-C K VC— WA
Residential ffj-�' Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor❑ G}Ckr C4, L�Q
dhere to min set back requirement❑
IN or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installationA2
New installation Planning Approval Required ❑
Cost of Project: Type of Construc Occ pan group:
`1900 0 C) �y
Strapped ❑ On Platform ❑ Bo ed 0 Sq.Ft. Floor Area:
New Locatiov/ff� Replacement
Qty. if.
A ca le Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A1C 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 License BUILDING