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04120141CITY OF CUPERTINO _ U 3 F O < $ .. Ofookwuh .. A Z Q Fcorrect. U W e a.�h' a^ +� ^° `^ n-' PERMIT CO,NTRACTQR INFORMATIQN --.. BUILDING DIVISION ;_'-------_-. BUILDINGADDRM: AIR QUALITY HEATING & AIRC Mrr"°04120141 7626 NEWCASTLE WNER'S NAME: PERMIT ISSUE DATA ' NADAR SHAMA 1233 PEDRO ST 12/9.n/2oo4 NE: SANITARY NO. CONTROL NO. - - (408)293-7138 ARCHD EC (ENGINEER: BUIIDING PE0.MIT INFO BLDG ELECr PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 9 Job Description I barely affirm that 1 am li¢vcd under provisions of Chapter (mmmendng Scclion INN) of Division 3 fact Businr, Pmfcssioa Code,and ylicenmis nm dnd=rr L e/ ' _ REPLACE FURNACE - u err c - - 'Bylc Conuacmr ii RCHITECI-S DECUA l I mastermind my plans hell W used as public recd Licensed professional OWI mBUILDER DECLARATION 1 hereby affirm Nu em exempt ! the Convectors License Law for the - .. ad following..a.(Sad.. ]f0LABus]•ar. and Professore Cafe: AnY city or county which require a Pmmit alter, impmw, demolish. which or repair any mactuummem re uira the t poor a�an its licensed pursuant use. Sant to 2a lbs visions ts offer such Actor's Lfile nse Law Chap=9 Nath.man Sq. FL Floor Area - .. Valuation (ret withSmuntmNBaDiviauo oft ftheBuanes..ianscLaw(Chapin9 ng wiNSenion]Bnd/MDntseff3 exampt Professions Cade) or Nat ho Is bavh for the alleged uempliaa. Any violation of h Nem from and the alleged erl) 0 " " — Occupancy e - P Y EYP cs or nation ]031.5 by anyhurt applicant for permit mbjttu Ne applicants N •civil penalty of 31.5 b not mom Nan ❑w hundred eofima (n50o). I,uavrw+oftlre pmpcny amY employees with waguM thev sole compewdon, Required Inspections - - will do Ne Work and the structure u not intended a offered forsale (Sec. ]004, Business and Professors Cade: The Comactors Cornus Law does ret apply m an owner of propenywho Wildsorimprows thereon, and whodoessuchwmkhimul(w through his own cmployeu, provided that such improwmcnu arc not intended mothered forsale. If, however, the building or improvement is sold within can year of completion, the owncr- Wildm will have five Wren of proving that he did not hdld or improve for purpose of - ❑ 1, owner of N= proper& exclusively contractingfesswith C] I..a. _ \ construct Ne f) Tat Ccan cted's - . B Cade:) The Cantrm a Business add not (Sec. sed La cereus Law doss not ePPIY m an owner of propenY who Wilds or imProvu @soon, and on o in property who on. such projects wiNaconvacmrtt)liceved punwntNWe Convattots'_.- License Law. 0 1 cardexempt ❑lam uemptunder Sec. .BkPCfa this saner Data WORKER'S COMPENSATION DECLARATION _.. 1 hereby affirm under penalty of perjury ane of the following declarations: I have and will maintain a Certificate of Consent to self -Insure for Workers Compm- -- - u provided for by Section 3]00 0( dm Labor Code, for the penfomatts of dm - -- - or which this permit is issued. ave and will maintain Workers Compensators Insurance, as required by Section - -. .. .. ;377'WfNC Labor Code. for Ne performance ofNe work for which Nis permit is issued.orkers no d lnwmnc Cama and Poliry number a e, r: Policy N.a .,:�;2 �.�f�q 2gf CE0. Ia CATEO EMPfION FROMWORKERS' _ COMPENSATION INSBRAHCE ((Tie section need not W completed if the permit Is foredo hundred dollars ($IIXO or less.) 1 comfy that in the performance of the work for which this Permit is issued, 1 shall not employ any person in any mannerm as to become subject the WorkerYCompenvtion Laws of California. Date Applicant NOTICE TO APPLICANT. If. after making this Ccr ificata of Exemption, you should beembe sabjoet to ft Workers eompclW tion previsions of the Labor Lade, you num comply with such provisions or this Permit shall W deemed mvoked. CONSTRUCTION LENDING AGENCY I hominy affirm that Nen is a construction lending agency for the performance or N= work far which Nu permit u issued (Sec. 3B9], Co. C.) Lenders Name Lcndcr's Md. 1 cenify Nal 1 have read this application and suss thn the move information is 1 agtce to comply with all City and county ondium us and seats laws relating to Wilding construction. and hereby auNodn nprueneatives of Nis city to corer upon the above-uncromeA Property for inspection purposes. (Wer) agme to seat, indemnify and keep harmless rise City of Cupertino against liabilities, judgments, casts and expenses which may in my way accrue agnand raid City in couegwnee of the granting of this permit. / APPLICANT UNDER TANDS AND WILL COMPLY WITH ALIP. -POINT "° Issued by: Date r SOURCE RE ATI �—��+ ��r Re -roofs D / Da nj�iy hurt of pylic V o^RDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant start or handier harudrus meudal Jas ticfinetl by the Coleman Municipal Code. Chapter 9.12, and the Health and Safety ode. elion25532(a)? Yp a All roofs shall be inspected prior to any roofing material being installed. Wtll N=,pplicam or tom building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove .it hanrdnucair contaminants as defined by tin Bay Area Air Quality Management all new materials for inspection. dmicO 0Yet 'pNu 1 have mud the hvallous mvetials not.inmcnu under Chmm,6.95 orthe Califon ria Health&SaretyCode, Sections25505,25533 and 25534, 1 understood data ifthe Wilding Jas not <unenlly haw • ¢nand Nu it h my rcrpomibilily m nrtily da= arta t of the imnnntswb' mon mnptior le issuance of a Ccnificatc or cnpamy Sig a[ o Applicant Date All roof coverings to be Class "B" or better Owner o autha Ifagmt an All CITY OF UPEkTINO Buildine D .1:1 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 �[•rv10WWI ce,I��7[_ •TiTirl77J�i I GENERAL CONTRACTOR I FAX # I 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 I 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 CI OF UPERTINO CITY OF CUPERTINO FURNACE/AC PERMIT APPLICATION FORM v,�Y/Z0/Y/ APN # / / l �. Date: /Z ZD 4 Building Addre s: — BREMFURN rr,�e so MECHANICAL Owner' N e: Phone #: - 2 - Phone: Phone: Licens #: - /3 t7 zz 74 9,9 Contact: Phone: Cupertino Business License #: Z BSEISMICRE Building Permit Info: BUILDING Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Descripti n: EPERMITFEE Residential omm cial ❑ ELECTRICAL For Residential In tallations: Mech Permit Issuance Attic E3ls` floor 2nd floor ❑ PPERMITFEE dhere to min set back requirement ❑ PLUMBING or Commercial Installations: Bldg Permit Fees Replacement same weight ❑ Additional weight (structural calcs) ❑ BPLANCHK Structural Calculations required for new installation ❑ BUILDING New installation Planning Approval Required ❑ Business License Cost of Pro'ect: W Type of Constru t n: Occupancy group: D� Strapped LJ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: New Location ❑ Replacement Qty. if Apply able Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN 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 BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPEPlv=EE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING