05080109 CITY OF CUPERTINO -� ' �'�' " "�"' `
BUILDING DIVISION PERMIT i,C0 "CTOR MORr1." IQN'`R
BUILDING ADDRESS: ABC COOLING & HEATING PFJM1T N005080109
10171 MANN DR
OWNER'S NAME: PERMIT ISSUE DATE
Ahk KATHLEEN ELLIOTT 31845 005
NE: SANITARY NO, CONTROL NO.
(510) 471-8181
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
300 LICENSED CONTRACTORS DECLARATION IbDescription
1 aacby affirm Net 1 Am licensed Molar provisions of ChapMr 9(ommcncin j o
2U with Section 7")of Division 3 of the BuainesaWP (ruiuv Code.an IiceveI
In full mmemoilit,. _ PLACE FURNACE & ADD A/C
jYs Z Uuaw Class Lk a v
TIF_ Date 517 1 CONNECT CIRCUIT MIA
HM CLARATION
1 mut raand my plans wall W used as public mamds
5 W Licensed Pofuasional / C
p OWNER-BUILDER DECLARATION L�OQvv
i 4 1 hereby.from that 1 em exempt from the ConuanaYs Llansa Law far the Dili!
Q
02 following mason.(Section 703 1.5,Business and Pofesstut Cade:Any city or county
which requlrw a permit to construct,&thee hnprove,de ulish,nr repair any aowoof j f% _
ZSn Prier o is ua
issno,alo requires the applicant Immch permit o Ric a signed mourecnh
�< that he is licensed pursuant to the previsions of the Contractor's Lkcnm Law(Chapter 9 Sq. Ft. Floor Area VVtu'a*8847
$ (commencing with Section 70D0)of Division 3 of the Doi.and Proftsinv Code)or
�.. Nat he is exempt thcmfom and the bash for the alleged exemption.Any violation of
Section 7031.5 by any applicam for a permit subjects the applicant to a civil penally of APN Number Occupancy e
not mare than live hundred Carlon(ss00). 32645028 . 00 P yTyP
O L u owner of to popery,m my employers with cages u Wet sole compeoution.
will do We welt,and the struerure h not intended ar alfervA fm sale(Sec.7044,Business
o
and Prefeas v Code:The Communes Umnse L.w does net apply le An&wear or Required Inspections
properly who builds m impaows thenen,and who does such work himself or though his
own employees,pmvixd Wet such improvements are an,Intended maBared forule.lr,
however,the building or Improvement Isa1d within one yea Ctenophores.the owner
builder will haw to burden of proving that he did set build or improve for yumore of
sale.).
1,as owner of the properly,am eactusinly contracting with licensed comrcmn an
construct the project(Sec.7044,Business and ProfeWom Cade:)The Contractor's U.
cave law does not apply o an owner of property who builds or improves thereon,and
who contracts for such prakuh Anita a conuacorrs)liceted pursuant In the Counselors
License Law.
I am exempt under See. -,B&P C for this myon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby alBare under penalty of perjury are,of We following doclantions:
I
have and will maintain a CxnIOwM of Consent to self-Imune for Warkeee Compen.
satipermit is
u provided fm by Sudan 3700 of the Labor Code.for the Performance of the
work for which this pis issued.
have and will maintain Worker!Computation IvAsursou, acquired by Section
3 of the labor Cade.for the performance of the work for which this permit is owned.
'y'
y Worley, Com tion lypsuraft tamer and Policy A4 14
C&met.. g"^ Policy No.:ATG I`F 1-5 O
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ThisocOan need not W completed If We permit isfarrev hound dollen($100)
or bass.)
1 eatery that in We mr1mor ane,of the work for which this permit is!wood,I wall not
employ any person In any maturer an As to become mbjact to the Workors'Comptaudon
laws of califomia.DAM
Applicant
NOTICE TO APPLICANT:IL after making this Cuoricaut of Exemption.you should
become subject to the Worker's Compenation provision of the labor Code,you most
.JO fonhwith comply with such provisions or this permit shall be deemed revalued.
zCONSTRUCTION LENDING AGENCY
[-rte IWmby AM.that Were is a construction lending aComes for the rulormance of
C the work for which this permit is issued(Sec.3097.Civ.C.)
WRQ IanderE Name
a z LendeewAddmt
U O I unify that 1 have mad this application and show that Use above Information is
W r'. coned 1 agree to Comply with all city and county ordinances and sus laws totaling to
0 rV^ building construction,and hereby mutative representatives of this city to enter upon the
W above-menwned properly for Inspection purposes.
(We)agree to saw.Indemnify and kap harmless the City of Cupertino against
y liabilities,judgment,cash and es uses an
which may In y my amus Against Mid City
(J7 in cammq sof thug lin is Permit.
APPLI( UM D AND W C Y 17H ALL NON-POINT Issued by: Date
S N
Re-roofs
Signature ofAppllwnVCrMtmAAor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dw wpllant or room Wilding accuput ave or handle hwardous material
as defined by the Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
tax,sawn z5s3 .)7
❑Yesx6+�_ All roofs shall be inspected prior to any roofing material being installed.
Will the mpBuani or future Wilding aceupam use equlpmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous Air Contaminants u defiad by the Bay Ams Air Quality Management all new materials for inspection.
7-quo
Nict7 —�� /
❑Yes zblu_
I have mal the hazardous materials requirements under Chapter 6.95 or We caiiro.
Health&Safmy Code,Sections 25503,35533 am!25534,1 understand that if the Wilding
es who evmml w a wnNt,that i y mapov dity o testify Jw occupant of the
al w musg p' motto cltricsk of Occupancy, Signature of Applicant Date
nerunulhodrtJagent Data All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCITYF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT #050 3`0 O 5'
/037 / q,-kL�
OWNER'S NAME: PHONE # cJ Z —IF,5 ZO
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:aq, —.e,b1
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
Ak Linoleum/ Wood
ME Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/ aS
Owner/�or Signa6re Date
CITY OF CUPERTINO
Q FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# 2 K UYJ¢ Date:
Building Address:
/03 7/
Owner's Name: Phone#:
973 - 9s9v
Contractor: O 'eC L7` Licens3e#
Contact: Cupertino Business Licceense#:
a.
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Job escri tion:
CLIVIQao�°6�z c 7'arIt
Resi ential -P� Commercial ❑
For Residential Installations:
Attic ❑ 151 floor ❑ 2nd floor❑
Adhere to min set back requirementIV
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Pro'ect: oo Type of Construction: Occupancy group:
t
Strapped El On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacemenX
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
I BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIILHAN A/C Units <= 10, 000 cf m MECHANICAL
BREMRECEPT Rec tl, Switch& Outlets ELECTRICAL
f BSEISMICRE Seismic Fee Res BUILDING
EPERMrrFEE 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 UILDING
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