03100014 rCITY OF CUPEITHNO p
BUILDING DIVISION PTRMIT CCINTRACTOR INFORMATIQN ".
BuI LDING ADDRESS: CONDITIONED AIR PERMITND03100014
OWNER'S NAME: 164B GILMAN AVE rersMlT LssuE DATE
DERRICK MAR 1719,12111-1
HIS:
(408) 374-6311 SANITARY N0. CONTROL NO.
ARCHITECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 l�
i020 LICENSED CONTRACT'OR'S DECLARATION '
'U6 1 hereby affirm Nel 1 am licensed under provisions of Chapter 9 commencip t Job Description
:Zw withSection lagp of Division 7of do Business rufcssinn. od Yliccm
- j
s�N in full force an fe • / /
igz L met,laa.i o rs L �FH2NACE & A/C y
it- Dam O C' aCL /
ARCI{I'IRC.. DECLARATION
ie IunticrstanJ my plans.hall Mused as Public rtcnrd K:V?
>au
t; Licensed PndasinnAl
SOWNER.BUILDER DECLARATION
I a 4 1 hereby affirm
that I am exempt from she Contractor's License Law fur the
p O following reason.(Section 703 1.5,Business and Professions Coda:Any city or county
t m which requires a permit t construct,Alter,improve,demolish,at repair any structure -
ciprions its issuance,also rettquites the applicant for such Permit tole a signed statement
VIPThatheislicensedpursuanotheprovisionsoftheCommoniLicenseLaw(Chapter9 Sq. Ft. Floor Area ValuJt
j y
$ (commencing wi ih Section 7AM)of Division 3 of the B usiness and Professions Crack)or
Nat he Is exempt therefrom and the basis for the alleged exemption.Any violation of 34245016 . 00
Section 7031.5 by any applieuma for A Permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more than five hundred dollen($500).-
1,As owner of the property,or my employ,.,with wages As their sole compensation,
will do the work.and the alnlclum is not intended or offered for sale(Site 7344,Business — tlHe9 ff3 Ct1005
m
and Professions Code:The Contractor's License Law does not apply m An owner of lR._
propeny who builds or improves thereon,and who doesch work himself or through his 303 - ROUGH M CHANI AL
own employees.provided that uch improvements are not intended uroRered formic.If, 304 — ROUGH ELECTRICAL
however,to building or improvement is sold within one year of eumphoon,the owner-
builder will have the burden of proving Nal he did not Wild or imports,for purpose of 505 - FINAL ELECTRICAL
ml`')' 507 - FINAL PLUMBING
co h es owner of ct property,.B exclusively contracting with licensed ennaamon to
construct shoes nott(Sec.]inownerofprotlrty who ns Wilds
Coaleu)Theorimpo Comnmon.Li SOB — FINAL MECHANICAL
who Law does r s apply m an owner of property who Wilds or improton Corton,and,
who contracts LA for.ucA projects with a contnctor(q licensed pursuant m IM Contnnor'.
License law.
❑lam exempt ander Sec. ,B&PCfor this recon
Owner Data
WORKER'S COMPENSATIONDWC RATION
1 hereby from under penally of perjury one At the following declaradmu:
7C1111-1
have and will maintain a Certificate of Consent m calf-insum for Workcts Compen-
n,uprovided for by Smtion 7]00 of to labor Cade,for the performance of the
for which this Permit is issued. -
have mtl will maintain Worker's Compensation Insurance u myuirttl by Swtion
of the Labor Code,for Ne performance of Ne work fm which Nis permit is issued.
orker's Const vacation Insurance asrier and Policy number ase-e S Policy
CERTIFICA 0T6 FEXEMTTION FROM WORKERS'
COMPENSATION INSURANCE
(lhissection need not M completed If the penult is foronc hundred dollars(Siff))
or Tess.)
1 certify dm in Ne performance of the work ror which this Permit is issued.I shall not
employ any Person in any manner so ante become subject o the Workers'Comp.nsation
Laws of CeliPomia.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Esemplian,you should
become subject to the Worker'.Compensation provisions of the labor Code,you must
D O forthwith comply with such pmvisiom or this Permit shell W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a construction lending agency for IM Performance or
:4 Y be work for which this permit is issued(Sec.3091,Civ.C.)
YQ LendcYs Name
z Lender's Addreas
Q 1 certify Nn I ban read this application and tut Nat the above information is
y Ftomcat.1 agree to comply with all city and county ordinances and tote laws mining to
building conuction,and hereby authorize mpresenmives of this city to enter upon do
UNa ahovoannamned propcny,for inspection purfmms
y (We)agree to save,indemnify and keep harmless the City of Cupanino epinst
N Iiebilides,judgmcnu.costs and expenses which may in any way accac against mid City
j in conmyuence ofdeg ntingoflhis Perm'
^ APPLICANT UNI ANDS D COMP WITH�ALLfo
AN.tO/N./P/DINT Issued by: Date f,
-
SOURCERE .a `%IC `v)
Re-roofs
Signature of ApplicaData
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Willy t applicant m future bulling occupant stere or handle Health a metrial
As defined by the Cupertino Municipal Cade,Chapter 9.11,and the Health and Safety
Cod.,Scaie.23531(A).+_.� All roofs shall be inspected prior to an roofing material being installed.Na
Will the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air cmrwciraannx as defined by the Bay Area Air Quality Management all new materials for inspection.
• utrict]
❑Ye.
1 have mad the humlous materials requirements under Chanter 6.95 of the Cali for
.in Health 6 Safety Code,Secdom 255(15.15577 and 25534.1 uMerstnd than if Ne building
Cosa ort coram �a tenon Wot y rapm� ililY m nosily the txtuPent of Nc
reyulrcmchu rss r rssuance cemratooracaPant�.f Signature of Applicant Date
p / All roof coverings to be Class "B" or better
Owner or authorized agent - Dam
410/02/2003 19: 22 5105363262 LEGALITIES INK PAGE 04
D 2 p `` l— North Bay Permit Service
J 1 .3988 Somerset Ave.
l CITY OF CUPERTINO Castro Valley, ' 94546
V.
FURNACE/AC B
cnr.ov i. Sla tii -ui3'
1tUPErZTiN0 P�,RMIT APPLICATION FORM
APN #
3 Z
4
Building Address
Owner's Name: Phone #:
Contractr Phone: / 9� .22-Z.0 License Ll S Z
Contact-. r- _ Phone: Cupertino Business Li ense #:
7 vvt. Q�rv.v Z z 3 3
Building Permit'Tnfo:
Bldg ❑ Elects Plumb Mech
Job Description: � O - //o 0 o v Tl l
Qct� I)L., }� ' G - ST - 6 0 'q-M Cine�. cst
Residential Commercial ❑
. s
For. Residential Installations: _ y
ISL ❑ 1° floor ❑ 2nd floor:!-t'
�dhere,to min set back requireriijenT�J
For Commercial Installations: ~~
Replacement same weight [] iAdditional weight (structural calcs) ❑
Structural Calculations required,'or new installation ❑
New installation Planning.App val Required ❑
Cost of Project: i Type of Construction: Occupancy group:
Strapped ❑ On Platform0 Bonded C3Sq.F[. Floor Area:
f
New Location ❑ Re lac xmant ❑
Qty. if f
Applicable U FecgfD Fee Description Fee Grou
1 BENERGY _ Ener BUILDING
BREMFURN Relocation of Fumace MECHANICAL
I BREMACO R A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN. A/C Units <= 10, 000 cfm MECHANICAL
t BREMRELEP, Rec tl, Switch & Outlets ELECTRICAL
t BSEISMICR Seismic Fee Res BUILDING
t EPERy1ITFEI �_ Elec Permit Issuance ELECTRICAL
1. MPERMITFE '� Mech Permit Issuance MECHANICAL
1 PPER[�fI'I'FE:0 Plumbin Permit Issue PLUMBING
BPERMFEE. Bld Permit Fees BUILDING
BPLANCHK ice! Plan Check Fee BUILDING
BUSLIC ' Business License BUILDING