05060061CITY OF CUPERTINO
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INFORM, QN
BUILDING DIVISION PERMIT
3�CON,TRACTUR
BUILDING ADDRESS:
CONDITIONED AIR
PERMrr"D05060061
OWNER'S NAME:
PERMIT ISSUE DATE
MI
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NE:
SANITARY CONTROL NO.
(408)291-222n
08 291-
ARCHITECl/ENGINEER:
-1CHITECT(Eh?GINEER
BUILDING PERM R INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 Mreby thin I licensed Chapter 9
Job Description
p
affirm am under pmvisions of (commencing
with Section 7") of Division 3 of the Business ArM Pmferames Code. and my license is
fofuBmru aria errs cqt. 4451
Lkcnu Class Lic.x
ADD ON ASC �/%�
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Dam Comruwr
ARCHITECTS DECLARATION
I understand my plans shall W used u public me.,&
Licensed Professional
OWNER-BUILDER DECORATION
I hereby .(firm Nm I am exempt Item due Contractors n Law for the
!r��,,
1/b/
o : A city.,
following emur1 A13I.q Business and Rnfeuiou Code: Any city structure
which) pWc i d , nr repair any suumutO
a a permit m cores
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✓ (C r/
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prior msl issuance,alsorequires themonsfor such perm's oice a Law statemcm
its ho die applicant forsu fameli
thommencttnsed pursuant mthe tW
Sq. FL Floor Area °f'>�f J,/`}r� p^ Valuation
(commencing with Sntion of Division ofdteeged Business
eBuacwsand PrsclawsCodr)9
Cod.)or
that he andtfDivisionr
Nal he is eumpt therefrom aria the bust for the alleged exemption. Any violation of
Any
Section 7031.5 by any applicant for a pe.I, subjects the applicant in s civil penalty of
3 ��PII'I&3MCr0 0
' �OCCUC anT
nwm.reNanfinhundreddolws(SSBuk
P Y YPe
❑ L ot owner r(Nd pmpunct w employcn with wren u Heir tele eompewness
will Pr fework, and the swemmisnotimm�ddorawit Buskin
is 7044, Business
and Professors not
License Law rocs not apply if an owner of
The comraane,
Required Inspections
property wh ldsor
property who imperious , and who aoessuch work himself
rid his
sac provi
Own employes,pmvidd that suchimPm
h fire ort@std for We. If,
offered We
ear
id whiartnot
of c
bowerce the building or impmwment is sold within one year of completion. the owe
builder will have Be, burden Nu W burden of preying tlitl not build or improve for purpose oof
of
0 1, u owner of the property, am eaclusinly contracting with licensed contracmrs in
courrocs the pmjrn (Sec. 700x, Business and Professions Code:) The Contercmrs Li-
ceme Law docs not Apply to an owner of propeny.who Wilds or improv Nemo, and.
who contracts for such projects with a contractor(, licensed pursuant On the Contractors
License Law.
0 I am nempt under Site , B k P C for his recon
Owner Dam
WORKER'S COMPENSATION DECORATION
1 hereby affirm under Penalty of Fatuity one of Ne following deelantioro:
1 haw and will maintain a Certificate of Conscnuo self-insure rot Worker's Compere
union, an provided for by Section 37110 of the labor Cad., for the performance of But
work for which Be, permit is issued.
,
an and will an ntaln WwkerS Compensation InYM[e, at enquired by section
3700 of the laWr Cod. for the performance of the worst for which Nis permit is issued.
My Workers Co usium. lumordttcarO..icc a Policy number art:
(�/, (�
Ca nicr:;�`rvolicY No.:1=—kms=
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Kthe permit is (wore hundred aollus SI00)
or less.)
I ernsfY tha in the performance of N. work for which this permit 0 issued, 1 shall nes
employ any person in any mannerse in in become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this C.nIDum of Exemption, you should
become subject an Out Workn's Compmssatir , pmvisions of the Labor Code, you most
faMwiN comply with wen Provisions or this Permit shall W deemed mvoked.
CONSTRUCTION LENDING AGENCY
I Wreby affrm Nos Nert is it romuuction lending agenry for Be performance of
the work for which thu permit is issued (Sec. 3097, Ci, C.)
Lends', Name
,
Lender's Address
I certify that 1 haw, reed this application am sum Nat Nn show, infom mance u
cones. 1 agree in comply with all city and county rudiments and sum laws relating to
building connection, and hereby authorise mpmecntatiwa of this city to enter upon the
above-menuoncGproperty for Purposes.
cameaon
( We) agree ro saw,, indemnify and keep harmless the City of Cupertino aga re,
Pewhich mayin any wayrecce egaiutBaia City
inCiariquinuC Ofu,cwuandOf INS
AcPLICAN cc of tht granting of Nis P
)WiL
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULATIONS
Asa Cy S
ypueen
Re-roofs
sq�e�rr res Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the, applicant or future building occupantsloreor handle haurdom material
as defined by the Cupenino Municipal Code. Chapter 9.11, and the Health and Safety
Code. OYeenn 355J2(a)? �Nr
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or dcvies which
If a roof is installed without first obtaining an inspection, I agree to remove
I,harardnus air conumimns as dined by the Bay Area Air Quality Management
all new materials for inspection.
m,ifO
D Yes CD!H"o
I have mad the hvardousmamrials requiremcnu undr Chap crii.95 of the Califor.
me Health& Safely Cede. Seeuoro 25305.35537 and 2553x.1 undrsuM thin if N. Wilding
don not currently hast arc a Nat it u my responsibility m notify the
- C�
/^��
o.ctmut of the
m iremcnu whim mustW/ yc��pnorwissuancc ofd Ccnifmam of Occupucy.
Signa re ofApplican Date
a7ln //.-x44. 9/bS
All roof coverings to be Class "B" or better
Ownerorethmi,W igcni Date
Community Development
10300 Torre Avenue
✓` Cupertino CA 95014
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
UPEkTINO
I
Building Department
JOB ADDRESS: PERMIT #
a1r66 00�/
OWNER'S NAME: ��kQ (y n PHONE #
GENERAL CONTRACTOR: F4X #
I am not using any subcontractors: S1126lG5
Signature V Date
Please check applicable subcontractors and complete the following information
66
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
61-9%b�
Date
s
•
CITY OF CUPERTINO
am, FURNACE/AC
OF
CUPERTINO PERMIT APPLICATION FORM
6s, -D c) l
APN # l (/ ^�7�05
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Building Address:
BREMFURN
l m', Kcc C -E Coop M,
, Qa Ci 50 I y
Owner's Name:
Phone #:
Tb r
:7cd)5 - C0- Lf6
Contractor: Phone:
License #:
1 lr ..OLGI - 9O
L AS(Go-
Contact: Phone:
Cupertino Business License #:
�c;. �I 1
� X33 �•1
Building Permit Info:
Seismic Commercial
Bldg ❑ Elect d;;-- Plumb ❑
MechGQ'
Job Description:
-flIe
ELECTRICAL
or
Mech Permit Issuance
Residential (C�,_ Commercial ❑
/ PPERMITFEE
For Residential Installations:
PLUMBING
Attic ❑ 1" floorpQ 2"d floor ❑
BldE Permit Fees
Adhere to min set back requirement ❑
BPLANCHK
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) ❑
Business License
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction:
Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable
Fee TD
17ee ne
/ BENERGY
_�U
Ener
ree urou
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
aSeismic
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILIDNG
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
/ MPERMITFEE
Mech Permit Issuance
MECHANICAL
/ PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
BldE Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
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