03100145 g CITY OF CUPERTINO ' a -ig ,."�TM
BUILDING DIVISION PERMIT sCQ NT 2iCTOR INFOItMATIO�Nt
BURDINOADDRESS: SCHAUMANN AIR CONDITIONING "ERMIT"°'03100145
ow NERDS NAME: HEATING & PLUMBING INC PERMITIESUEDATE
MICHAEL BENRNRON
1NL:
(408) 428-0640 NOSANITARY . CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB Mmi
0
!toLICENSED CONTRACT'OR'S DECLARATION
C 1 hereby efrrm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section will,of Division 3 of the Business and Professions Code,end myliccn¢is
mmnmreea «r ., 7�00� y REPLACE FURNACE & ADD A/C
q_ Lkcnscn' •I+�• Lk.a
I-� Dam LCCa me r
RATION
3p m ARARCH ,wM a
i a I dcrsta�{1 le and Alit records
apt; LiecaudProfuooul
S OWNER-BUILDER DECLARATION
f 1 hereby affirm that I am exempt from the Contractor's License Law for the
p o following Mason,(Section 703 1.5,Business and Profusions Code:Any city or county
5$ which acquires a permit m construct.alter,improve,demolish,for repair any sbumum nnn
prior to its issuance.also requires the applicant for such permit to file a signed mormem
C thathcislicensedpursuanttothcpmvisionsOfNeCommun'sU.nxlaw(Chapter9 Sq. Ft. Floor Area Valuation
zF❑ (commencing with Section 7")or Division of the Business and Profcseims Code)or
`3$ that he is exempt themfmm and the built for the alleged exemption.Any violation of 35713020 . 00
Section 7071.5 by arty applicant for a permit subjects the applicant to a civil Finally of APN Number Occupancy Type
not more Nan rim hundred dollars(M). p y yp
01,As owner of the Frwity,or my employees with wages As their to compensation, ~ !'
r
will do the work,and lheshocmm is not intended oroffered lorsawlam.iousa,Business IkRF'quired,Im;
and ProfeSaloN Code:The Centrawmre LIRRY Law does not apply m an oWMr of (F pec[ions
own cnywho builds idedthowsth Impr ve who AM notihwoh himselfor hiehowever.theuilding or imouuchimprowmenain ne rar ofdof mplefied fornk.ILbuilder .ill ban the b rden of proving hat he didn arc year orcomole forn.theower-builder will bew Ne burden of proving Nat he ditl not build or Improve fur puryoee ofsok.).0 1.as owner of the property,am exclnsvely contracting with licensed convectors toDQ contract the pmject(Sec.7044,Businw and Rofusioat Code)The Contrumi s LT. .
cense law does not to m owner of property who Wilds or improves thereon.and
who contracts for such pmjcca with.Conti licensed pursuant o Ne Contractoh
Licame Law.
0 1 am exempt under See. B dk P C for this reform
Owner Data
1031EWORKER'S COMPENSATION DGCLARATION
I thereby.10m under Finalty,of perjury one of dm following declarations:
hive and will maintain a Ccnifcom of Consent to Act Nostra for Workch Compere
n,fo provided for by Section 3700 of the LJWr Code,far the profAonArm of the
for which this permit is issued.
have and will maintain Worker's Compens tion Insurance,as required by Section
of the Labor Code,for the performance of the work for which this permit is issued.
Worker'r-sCompewtirn Insumms uric and Pollii/ry number art:
ver:als-7w' Puny plb.:Lt weze - g-
CERTIFICATE OF EXEMPfIflf�CROM WORKERS'
COMPENSATION INSURANCE
(This it.aid not hecomplowd if tK permit is(.a.hundred doll.(11110)
Itis.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an As to become subject o the Workeri Compensation
Lew,of California.Dam
Applicant
NOTICE TO APPLICANT.If.after making this Cenifum of Exemption,you should
become Subject to the Worker's Compensation provisions of the labor Cmle,you most
7p forthwith comply with such provisions for this Permit shall W deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
I hereby°Rum that Nem is a eonsraellm lending agency far the performance of
Y.,7 the work fur which this permit is issued(Sec.3897,Civ.C.)
jLAra It Name
= z Lendcrs Address
Q I certify that I hers read this application and saw that the awn information is
correct.I agree to comply with tll city and county ordinances and Imre laws relating to
0 V building construction,and hereby authorlre representatives of this city to color upon the
CL,
cella-mcntirnedpmpcnyfor
and
impaction purposes,
hichma
(We)agree m lave,indemnify and keep harmless the City of Cupertino against
fA Iiabilitiu,JWgmenu.costs and expenus which may in any wyurnteagainst imag City
;J A APPLICANT
NDERSf the mingofthispermit. p Issued by:
Date
APPLICANT UNOERST AND WILL COMPLY WITH ALL NON-POINT
SOURCE REG LATI_0
Re-roofs
Si tore of ApplicanVCanvecmr pate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupenumm or handl,heard..,material
u defncd by the Cupertino Municipal,Code.Chapter 9.12,and the Health and Safety
ode,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
0 Y. Q Ng.-
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it handouts nit contaminants fo defined y the Bay Arta Air Quality Management all new materials for inspection.
tone'?
0 Yet
1 hammed Ne hanadous materials requirements under Chapmr 6.95 of the C.Iifn,.
nit Haslth k SafctyCode,Sodom 25505,25533.nd25534.1 undersand thatif the Wilding
dors not currently haw a anan4 but it i,my responsibility to andly the mcupant of the
requirements whit tM cl poor m Issuance ora Certificate or Occupancy. Signature of Applicant Date
JPJ.�Y3
own r:rthoa sd agent te All roof coverings to be Class"B"or better
CITY OF CUPERTINO
Mao FURNACE /AC D
` CUPERTINO PERMIT APPLICATION FORM
APN# 3s 7
/ Z a Date: L o p
Building Address:
C Ccn
O per'sName: Phone -
' �enenS� �D� 733 - ?05�
Contractor: License#:
glo ACD3
° � Pho #•
/C4 D 2-3 (Faf9
pliant/Contractor:
Building Permit Info:
Bldg le Plumb Mech
Job Description:
Residential: FwtKev 41C Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: o
Type of Construction: Occupancy Group:
• Qty ..
A li a lq Fee ID Fee Description Fee Grou
BENERGY Ener -BUILIDNG
MF
BREURN 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 BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE PlumbinR Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC I Business License BUILIDNG
'/ � .
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