03040048 77;-TTY OF CUPERTINO
j BUILDING DIVISION PERMIT ,CONTRACT° WIN '.
-° ItMATION
,rsl .tt �,. '•* 3k .TsL buy iRid'u S'ndZ` '
' BUILDINOADDRESS: PERMIT NO.
22821 A MEDINA LN A & H HEATING 03040048
OWNER'S NAME: PERMIT ISSUE DATE
PONCE ROBERT A AND SCOTT-PO CE770 CHESTNUT ST 04/08/2003
NE; (408) 279-0722 SANITARY NO. CONTROL NO.
ARCHITECT/ENOINEER: BUILDING PERMIT INFO
BLDOO ELECT PLUMB MECHO
o LICENSED CONTRACTOR'S DECLARATION
1 hcrohy in that I em limned under I m isloas of Chapter 9(commencing Job Description
x with Section if00 Dlvlelan 3 oflhe 11winenmdPrufcad...Cndo,melmylimese is
^< infuli forte et L
$�z LkenO o un.• REPLACE FURNACE (88000BTU) F..I�A��..®
Tete Conlncror /
ARCHITF.CI'S DEC A ION �5
'� I undcntanJ my phos andl he stud ss path m menrda 2003
LicensedPmftemond
APR 2
OWNER-BUILDER DECLARATION
I hcrehy affirm that I emtoexempt from Ne Cantsaclors License law for the
�00 following mason.(Section 70313,Business and profession Cade:Any city of county BUILDING
$ which requlrea a permit to construct.alter,borrow.demolish,at mpdr any struclum
FZi prior m its issuance.also sequin,the applimnl far such permit m rile a signed statement
0
that he is licensed pursuant toNcpmvisionsofthe CommetsiLicense Uw(Chapter 9 Sq.Ft.Floor Area Valuation
sommencing with SeNon 7000)of Division 3 of the Businessand Prof"dansCcec)or $2500
Net he is exempt Nelefmm and Ne basis for the alleged exempdon.My violation of
Section
e moons than R.hundred applicant
forars a permit subjects the applicant to a civil penalty of 3�py Nbr417er 0 0 Occupancy Type
❑1,"owner of the property,or my employe"with"In U their Ole compensation, L3D 7
will do Ne work.and Ne woc u ,is not intended or offered for sale 7004,Business
and Professional Code:The Comment'sLicense U.does net apply to an owner of 301 - ROUGH FpMIhMthNLSctlOnS
properly who buildsor improves themun.and whodmaauch work himself or through his 303 - ROUGH MECHANICAL
own employe",provided that such improwments an,not Intended orofferod fursale.if,
however,the building or improvement is Old within one year ofcompletion.the owner- 304 — ROUGH ELECTRICAL
builder will have the burden or proving dot he did not build o improve for purpose of 505 - FINAL ELECTRICAL
C I.as owner of tM pro edy,am excitalwly,contracting with licensed Contractors to 507 - FINAL PLUMBING
mmtruct the project(Sec.Toa,Business and Prot"don Code:)The Com"Clos's u- 508 - FINAL MECHANICAL
cense Law does not apply to an owner of property who builds or Improve Neuron,and.
who contracts for such projects with a contract.,B)licensed pursuant to the Contractors
License Law.
1 am exempt under Sm. .B&P C for this mss.
Owner Data
WORKER'S COMPENSATION DECLARATION
^f I hereby affirm under penalty of perjury one of de following declarations:
hoe and will maintain eCe dficaton 3700 or Consent mCode.forn for WmkeYa Comf the
on.r provided for by Sections 3700 of the labor Code,for Nn pcdonnenec of the
work for which this permit is Issued. _
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 or the Labor Code,for the pedotmmcc or the
work f Ich this permit la issued.
My Warec' Cmppens,fie Insurance.rticr and P 11ey. a -
Cor: V Paley .. yV/5/02Q0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CMN section need not be completed Iffilm permit Is fnone hundrod dollen(SIM)
or leas.)
1 mnify that in the performs..of the work for which this permh Is Issued.I shell naw
employ any person In my manner an as u became subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Comficam of Exemption.you should
become subject ro the Workers Compensation pmvidonr of trm Labor Code,you most
O foMwith comply with such p...for.m did.permit shall be bounce revoker.
„zt M CONMUCf10N LENDING AGENCY
(—i I hereby aKrm that Nen b•coasOctian lending agency for the Performance of
C the work for which this Permit Is Issued(Sec.3097,Civ,C.)
W A Lender's Name
Lender's Add."
U i certify that 1 have reed this Application and she that the show Information is
Ii.F correct I agree to comply with all city and county ordinances and state Is"misting to
0 U hullding conswmion,end hereby authorice mpmeenutivus or this city to enter upon the
W .hove-mentioned property for inspection purposes.
(s.ju agree to cove,Indemnify and keep harmless he City ru Capetianagainst
sagainstold
City liabiliti /7
y inconsequenc of ms,
sell
expenses which may In any troy accnm aSdnn aald City
C.1 APPLICANT UNDn"Soling Sthb pe WILL COMPLY WITH ALL N -P INT Issued by: Date
SOURCE REG I S
�— a5 Re-roofs
Signa u pplicam/C tractor DM
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oeupant atom or ltandk hvarduus material
u dofimed by Ne Cupertino Municipal Code.Chapter 9.12.and the H"IN and Safety
Conn.Seeder,255320)7 All roofs shall be inspected prior to any roofing material being installed.
❑YuNo
Will the applicant 0r utum building occupant use egolpmenl or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
It herardous air contaminants as defined by the Bay Area Air Quality Managemmnl all new materials for inspection.
nrmO
❑ °��Yes r
I have road the hmardous en rids mquirommi under Chapter 6.95ofNeCsifnr-
niaHcalth&sakaycol Secu 505,23533ata1Z5534.lundcnwdthuifthebuilding -
does not cunenll a to ,that II is my m seralbillty u notify the ectusem of the
roydro I i ab at atKim mi. aaf.ecmlreor QCC upwcg Signature of Applicant ,Date
0 r ..th.dued spent Dg� All roof coverings to be Class"B"or better
1y
CITY OF CUPERTINO 0
FURNACE /AC
{ CUPOCEiCTiNo PERMIT APPLICATION FORM
APN # 3 Dote:
Building Address:
Owrier's Name: f ome,6 AD i3 , Z q6 —�O �
Conti h 46T6icense# D
Contact: � / o' 7q - 7Z�
Appli a ont ctor:�
Building Permit Info:
BldaElect Plumb Meeh
Job Description:
Residential: i
Sq.Ft, Floor Area: $/Sq.Ft.:
Architect/Engineer: Val io FjCj
Type of Construction: 1� Occul p:
Qtif
A icl le Fee ID Fee Description Fee Group
BENERGY Energy BUILDNG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tI, Switch,& Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elea Permit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
b