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04070183 ? CITY OF CUPERTINO a 0,at.+�"w= BUILDING DIVISION PERMIT - ,' 1l ,TR.biCT'Q T FORMATION, ..- BUILDING ADDRESS: BECKS HEATING AND AIR COND r!RMNO04070183 20920 MCCLELLAN RD OWNER'S NAME: PERMIT ISSUE DATE ST. JUDE ' S EPISCOPAL CHURCH 1107 CAMPBELL AVE, ONE: SANITARY NO. CONTROL N0, 4083582172 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH 0 0 0 0 _Op LICENSED CONTRACTOR'S DECLARATION lob Descriptio cre �f1U(I I bby affirm that I am licensed under provisions of Chapter 9(commencingn with Section 70M)o'Division 3 of Ne Busincoand Prefcsshins Code,and my license is roJ/—A 'tea j Zinfullforesmul.Rect. INSTALL ASC AUG License Class Lic.N — Dam Contractor 122004 ARCHITECT'S DECLARATION �i I moursmnd my plans that]Well u public receNa � A Licensed encs Professional �® p. 3 TVP OWNER-B"amp,form, DECLARATION Comment's d c O I hereby .(Sere Nat 11. exempts an the Cvnwcor'a:cense Lew for the i O O following moon.Permitt IID 1.5,Bmfer.and vert de io demolish, Cooke:Any city or county $to which requires a permit re uires the alter.impose,demolish,nr repair any awclent F to hat heor its coned e,atm requires the pre previsions nion of for such pe rat's Lice se signed alaumcm - £ < (commescingwiturstion7 )ofDivions3ofthef te mracmr'andProlaw(Chaplcr9 Sq.Ft. Floor Area Valuation y $ (cat he is (commencing it therefrom and t Win the the Busineies xempt on.Any vi Code)or that he Is exempt therefrom and Ne bola for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects Ne applicant in a civil penalty ofOCGD araC not inose Nan Eve hundred delta.($500). 6r P y `J Pe ❑1,as owner of the property,or my emplvycea wish wages m thairaole cooperation. will do Nework.and the structure isnot immided or offered forule(Sec.7041,Biomass and Phonemes Code:The Commcor's License Law does not apply to an owner of Required Inspections property who bui Ids or improves therron,anal does such work himself or through his awn employees,provided Nat such improvemenisue nolinanded oofferrd forsake.If. ' however.the building or improvement is sold wiNin one year ofcomplcuon,theowner- Wilder will have he burden of moving Nu he did not build or Improve for purpose of .til as owner of the property,am exclusively contracting with licensed conuacors to c0 wet the project(Sec.7044.Business and Professions Cade:)The Continuo's U. cense law don not apply to an owner of property who Wilda or improves former,and. who contacts for such projects with a comeselor(s)Incensed Woman to to Con ommes License Law. ED lammonsinioulculeco ,B&P C for this owner A D "Cie ITp 1'SOMPE \TION ECLARAData WO 1 hereby affirm under penalty of perjury one of Ne following declarations: I have and will maintain a CmiBeou of Conscm to self-intim for WorkeYSCooper. .tion,ss provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is noted. ❑I have and will meimst Workers Compensation Insurance,me required by Suction 3]00 of to Labor Cade,for the performance of Ne work forwhich this permit is issued. My Workers Compensation Insurance carrier and Policy number am: Carrier. Policy No.: , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE . (Thisece ien reed nolhecompmead IOhe permit is proven hundred dollars(SIM) rr Itss.) 1 cenlfy Nat in to performance of the work for which this permit is issued,l shall nut employ any person in any manner so aa to become subject to the Workers'Compensation _ Laws of California.Date Applicant NOTICE TO APPLICANT.If,after making this Confine of Exemption,you should become subject o NC Worker's Compensation provisions of to Iahvr Code,you must ,J O foMwith comply with such provisions or its permit shall be deemed revoked. ,'�a" CONSTRUCTION LENDING AGENCY r��+ I hereby affirm Nat Nem is a construction lending agency for the performance of CG ti to.,it for which Nice permit is issued(Sec.3097.Civ.C.) U A IsndcYI Name .7 z Lender's Address U,Q 1 certify Nat 1 have mad Nicety and coon and stem Net and above information is 0 U buildin I ague to comply with all city and county oN fives of and mace laws rising upi s O„ abbuildingvconaweliend hereby atNorlIDmpfetealOtMb of this ally to enter aeon tlC CL W above-ms.judg d propertyst for and exp uses purpose¢ (We)agree to save.indemnify and keep Will the City of Cupertino against 1Z liabilinconiequencmonu.cos.ing expenses powhtch may in any way we=against said City C)z in consequence of to granting of this pewit. - a..i APPLIC STANDS AND WILL COMPLY WITH ALL NON-WINT sued by: -SOURC ATI 5. t— :::V Date si ewrtarA II .U._caor Re-roofs Bq pVc+NAZARDOUSMATERIALSDISCLOSURE au Type of Roof Will the applicant or future building uccupem sore or M1antllc haallous im udal as defined by to Cupertino Municipal Code,Chapur 9.12,and the Health and Safety Code,Sectors 25532(.)? All roofs shall be inspected prior to any roofing material being installed. ❑ Yes Will the applicant or fnum building aneupxm no equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit Woodous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Oixuict? �_�_LLI [3 Yes No I have mal Ne ha ardousmmriels mquimmcn¢undcrChapur 6.95 of the Califor- nia Health&Safety Cotic,Secuom25505,25533 and25534.1 undersand Nazirthe building does not cern have a mnanl,the it is my nomonsihility in notify the occupant or the col 'ch st be mm pdoru issuanm ofa CeniOca Signature of Applicant Date voter m mrfl. eel Dake All roof coverings to be Class "B"or better Community Development e 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF UPERTINO Fax(408)777-3333 � Building Department JOB ADDRESS: 'Lc,c�Zo t C�� K PERMIT ## �0 7b/ g3 OWNER'S NAME: S� `�� S lSc.'9'P A� PHONE # / - C / 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 ✓ Heating 5 Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner ac r Signature Date Sag CITY OF CUPERTINO FURNACE/AC o . UPEkTINO PERMIT APPLICATION FORM APN# Date: ^ (J Building Address: 2-, Own r's�Vame: Phone#: / Contractor: Phone: License #: -z SS°t \oD Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ ❑ Plumb ❑ Mech Job Description: Residential ❑ Commercial ❑ For Residential Installations: Attic ❑ 15` floor ❑ 2nd floor❑ AJ&kdhere to min set back requirement❑ 'or Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calc oris required for new installation El New installa ' n Plpnning A oval Required ❑ Cost of Pr ject: �o Type of Cons c n: Occupanc Strapped n Platform el Bonde, Sq.Ft. F or ea: New Location ❑ Replacement ❑ App li b e Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILDING ( 13 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 �/� 6 3