03090193 CITY OF CUYEB'PINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
11U II.DING ADDRESS: PERMIT NO()3 0 9 0 19 3
OW NIRS NAME: PERMIT ISSUE DATE
CASA DE ANZA HOA 03
JNL: SANITARY NO. CONTROL NO.
ARCHI9LCT/ENGINEER: ED PERMIT INFO
BLDG ELELT PLUMB N't
+op LICENSED CONTRACTOR'S DECLARATION O O O O
4as F 1 hereby amrm teat 1 am licensed under nnovimons(if Chapter 9 lnnmmonarg Job Description
Zto wills Secon 9( ycfDiviainn3oflhe Rusin nil PrtfedirnsCde,nnd my linen.is
say in full force Per ct ry� 4'y
;da, ur.nua.. tt ! REPLACE FURNACE & A/C p
o Dale cono-aa N., K Lee 4 CONTRACTOR: PACIFIC NORTHSTAK/r ECH.
e uJ
E o I u d .lanARCHIC �� ARATION
der lasshaCmblieocean,
. 1_J
ts,
Licensed promotional 1U
OWNER-❑UILD17R DECLARATION
aS 1 hereby tiff m Thal I am cxclum form the Con,mamr's Liconse Law I'ur Inc
Ho following reason.(Section 71131,,Business and Pmfuesions Cade:Any my or mumy Up
m which requires a pencil In construct,alter,improve,dominion,or repair any structure
-iy primal its isauance,also requires theappnicam forsuch Prrmit ba file a signedxlnmmem
;so throw srcansadpmauanttu[lie PrevialonanrmecanoaemrsLieenaeLawechapmr9 Sq. Ft. Floor Area ��UfValuat"777
�� (commencing wish Section]f%l0)of Divisionl of the Eusirearand Pormoiom Crnm)or
3$ that he is exempt mrrefram and Ne basis for the alleged exemption.Any violation of
Section 71131.5 by any applicant for a Permit subjects the applicant to a civil Penalty of 3 WN2vD18ber00
not more man Eve hundred dollars(SSW). Occupancy Type
t]1,as owed,of the pmpeny,or or,empirical,with wages as their sole mrniamaim,
will do me work,and the structure isnot intended m offered for sale(Sec.]NW,Business
and Professions Code:The Cnnlrsctor's License Law does not apply to an owner of qC130ns
pmpeny who buildsnrlmpooer,Promotional who d.,.aA work himself orlhrough his 301 — ROUGH �Ulkl 1N
Own emplayces,provided that such improvements are not intended or offered for sale.If, 303 — ROUGH MECHANICAL
however,the building or ire provemenl is sold within one year Of com ple ion,Ne owner.
builder will have the burden or proving that he did not bund or improve for pomoe or 304 — ROUGH ELECTRICAL
sam.).
❑1.as Owner of the property,am exclusively contracting with licensed contractors to 505 — F I NAL ELECTRICAL
,mama the p.,ad(Sec.]tun,Baslecss and Professions Code:)The Citmoso no's Li. 507 — FINAL PLUMBING
rearom law tines not apply to an owner ofproperty who builds or improvers income.and 508 — FINAL MECHANICAL
who continuant for such projects wills contractors)licensed pursuant to the Contractor a
Licene Law.
❑ I an,exempt under Sec. ,B&P C for this remnn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby a(rnn comer penalty of perjury one of the following dcclarminno
have and will maintain a Certifienm of Consent to left msua for Worker's Compen-
ns provided far by Section 3700 of the labor Code,Our the peAmmnnce.(,he
%0for which this permit is issued,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of Tho labor Code,for Ne performance of the work for which this permit is issued.
My Workers Compensation Insurance artier a d Policy numb
Cam r, SO,No.:
CERTIFI ATEO-EXEA ION FROM WORKERS'
COMPENSATION INSURANCE
(This welimt need not be rnmplemd little permit is foronr hundred dallars fill,))
Itss.)
1 ecnty that in the performance of the work far which this Permit is issued.I shall not
employ any person in any manncr.so as m hecomc subject to the Workers'Compensation
Laws of California.Dal.
Applicant
NOTICE TO APPLICANT:If,after making this Cenilinne of Exemption,you should
become subject tu the Worker's Compensatlnn provisions Of the Labor Cola,you mus(
O forthwith comply with such provisions or this permit shall M1c deemed revoked.
ti N CONSTRUC`HON LENDING AGENCY
1 hereby anon that more is a coOeBuainn lending agency far the performance of
x Ire work for which this permit is issued(Sea 3(197,Civ,C.1
JJQ Lender's Name
n. z Lender's Address
J O 1 certify that 1 have read this application and state that Inc above information is
y H correct.1 agree to comply with all city and county ordinances and stem laws mining m
�U building conclor ioq and hereby aulhorim repmsemladvcs of this city m enmr upon the
W ahovcmejudg tl property for ie penies purposes.
(We)agree to save,indemnify and keep harmless the City Of Cupertino against
�rjjliabilities.judgments,costs and expenses which may in any way,deme againslsaid City
J in cnnuqucncc fm grunli of this crmit.
APPLICANT NDERSTA DSA WIL OMPLY WITH ALL NON-POINT Issued by: Dale
SOURCERE LATI NS.
Re-roofs
ignamrc PPndaHAZOARDOUSMATERIALSDISCLOSURE—ourDatc Type of Roof
me applicant or future building occupant store or handle naraNuus material
as derby
the Cupertino Municipal Code,Chapter 9.12,and the flcanh and Safety
.ode conn 255320)?
p Yes 1k9t, All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
ha....ba s or contaminants as darned by me Bay Area Air Quality Mamagcment all new materials for inspection.
n?
❑Yes
I larva read the bvardnus materials mtluiremmnu under ,Chapter 6.95 of the Califor-
nin Hcaltn&Safny Chill,Sad ars 255(1/33arrol1 undcrL nil thinifme huiming
does not curtc dy huva tenant, aliy rcepomihilitym mmi,thence,hn(af the
regmrem' worn o bcmat darame oricatorome rocrupamcy. SignatureofApplicant Date
stridor dti ag.nt y� Dam All roof coverings to be Class "B" or better
CITY OF CUPERTINO
CQ� FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# 2, _ Date: U�
Building Address: �•V� r
Owner's Name: Phon #:
SG -O 2-8
C ntractor: Phone: License#:
a rzih %iA 56 8 - 0,191 C # 769771
Contact: Phone: Cupertino Business License#:
5-6 ' U1Q
Building Permit Info:
Bldg ❑ ElectAll Plumb Mech
Job Description:
Residential ❑ Co ercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2"a 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 Plannin A 1 Re aired ❑
Cost of Pr et: Type of Const c o - Occupancy r
Strapped P1 tform ❑ Bonded Sq.Ft. Flo e
New Location ❑ Replacement
Qty. if
li a Fee ID Fee Descri tion Fee Group
\ BENERGY Ener 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
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMTIFEE Mech Permit Issuance MECHANICAL
PPERMIIFEE PlumbingPermit Issue PLUMBING
BPERMFEE BldgPermit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
� l