03110137 CITY OF CUPERTINO r la
BUILDING DIVISION PERMIT CONTRA CTORANFORMATION 5,
(BUILDING ADDRESS: PERMIT NO0 3 110 13 7
186 LOREE AVE
W NER'S NAME: PERM T ISSUE DATE
Y CHAN 11/21/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
CJ O D 0
+Op LICENSED CONTRACTOR'S DECLARATION lob Description
ee UF� 1 hereby&trim that 1 am licensed under provisions of Chapter 9(commencing P
$�W with Section 7")af Division3ofdc Busbessand PmRsou.s Code,..my Ilan.is �'����®
7,y in full force andefrca REPLACE FURNACE & A/C
a�? Liccnse Clot Lica
'FaWWWy Dau Contractor
qct Iunderstand mypl nsshal M ';ed°aspucrecord DEC 1 7 2003
5dU
Licensed Pmfcuionel
3
OWNER-BUILDER DECLARATION
f 1 hereby affirm that I am exempt room she Contractor's License Lew for the BUILDING
p O following romnn.(Section 7031.5,Business and Pre@uions Code:Any city or county
5$ which rcyuirca a Permit to construct,alma imp...ve,demolish,or mpuir'any structure $1000
ZtPoor In its issuance,also requires the applicant for Such permit la file a Aigncd n2ocroenl
that he is licensed pursuant 10 the previsions of the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
$ (commencing wi th Section 7")of Division 3 of the Business and Professions Code)or
that he Is exempt therefrom and the boo far the alleged exemption.Any violation of
Section 7031,5 by any applicant for a Permit ubjects the applicant to acivil Penalty of car Occupancy Type
not more than five hundred doll..(15(10).
❑I,uowvr car de pmpeny,or my employcee with wsgvu their tole eompewelon,
will do the woh,end the stveturt is not imm�ded oroRertd footle(Sec.7814,Beainess
and Professions Code:The Comeactofs License law arcs not apply to an owner of Required Inspections
prnpeny who builds or improve Burton.and who does such work himself or through his
own employees,provided that such improvements are not intended oroRemd for Ile.IL
however,the building or improvement is sold within one you of completion,One owner-
builder will have the burden of proving Nat W did not Wild or improve for purpose of
side).
kI,as owner of to property,am exclusively eommcting with licensed contractors to
c tract the project(Sec.7044,Business and Pro(essiav Code:)The Conuactor's U.
cave law does not apply to an owner or pmpeny who Wilds or improves demon.and,
who contents for ch pmjecu wish a contractor(s)licensed pursuant to de Contractor'&
License Law.
❑l am em dbander Sec. B k P C for this wason
Date
WORKER'SCOMPENSATIO RATION
I toothy Mr..under penalty of perjury one of the fallowing larations:
1 haw and will maintain a CerMicam of Consent to selr-insum for Wo lmesCompcn-
sation,uprovided for by Section J]00 of that(ober Cnde,for the Performance of the
work for which this permit is issued.
❑I It
and will maintain Workers Compensation Insurance,u required by Section
31M of the labor Code,for the performance or she work for which this permit is issued.
My Worker's Compensation Insurance carder and Policy number am:
Cartier. Policy No,: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Godo section need not be comple¢d iltbe permit Is rororm hundred dollars(1101)
or ic.Q
1 cenify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any maromrso as to become subject to the Workeri Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Cenifinm of Exemption,you should
become subject to the Workeh Compensation provisions M the labor Code,you most
0 forthwith comply with such provisions or this Permit staff he deemed to olmd.
Z M CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a conswoion lending agency lot the Performance of
Y, r��+ she work for which this parrot is issued(Sec.31N7.Civ.C.)
IgA Q Lender's Name
=Z Lcndcr'a Addrcaa
U C) 1 coldly du 1 have read this application and state that the show information is
F coned.l agree to comply with all city and county ordinances and Stam laws missing to
0 building construction,and hereby amormine mpresenmtins of this city to cuter upon the
�+a above mentioned pod rty for inspection on moos,
(We)agree to save,indemnify and keep harmless the City of Cupertino against
F" fA liabilitiv,judgmenu,cosu endespcves which mayin anyway accrue agamstmic City t
UZ, in consequence oofj the granting or this Permit.
APPLICA UNDERSTANDS AN WIL C01. MPLY WITH ALL NONPOINf Issued by: Date
SOURCE GULATI07
Re-roofs
store of App icanuContrutor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle haeudous material
u defined by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
Jc,Section 35532(a)7 All roofs shall be inspected prior to an roofing material bei. Installed.
❑YesNa P P Y g g
Will the applicant or future building«caput use equipment Of devices which If a roof is installed without first obtaining an inspection,I agree to remove
alt h....does air conmminants as defrncd by the Bay Arca Air Quality Management all new materials for inspection. -
istrim7
❑Yes yNu
I how mad the haxan oes materials requirements under Chapuril 95 orlhc Caliror,
nia HcolthkS Code,Sections 35505.]5533 and 255th.l touecund thuifthe Wilding
tlms not cu Iy how a tenant.that it is my respovihilisy m notify tbe oeeuPanA of the
requirtmo which most bemclpri conceniheaefOceupancy.y - Signature of Applicant Date
'2/
wnerorauthorizedagent D. All roof coverings to be Class "B" or better
CITY OF CUPERTINO 03 / C:D /3
FURNACE/AC
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # 37S. ! o o Date: Z 3
Building Address:
Owner's Name: Phone #: -20
<�, , � g .
Contract ,. Phone: License#:
Contact: Phone: Cupertino Business License #:
i
Building Permit Info:
1
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
v �
Residential Commercial ❑
For RWdential Installations: i
Attic 'rJf ls' floor ❑ 2"d floor❑
Adhere io ruin set back requirement❑
For Commercial InstallationI
Replacement same weight Er Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑ +�
New installati n Planning A rov e it ❑
Cost of P cy / , O ype of Construction: OccupIyAurP r-
�/ O
Strapped tLJ On Platform ❑ Bonded ❑ Sq.Ft. Flo ea:
New Location ❑ Replacement E-1
i
Q . if
A 1' a le 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
BSEISMICOM Seismic Commercial BUILIDNG i.
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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