04050025CITY OF CUPERTINO^"^.�+w"�%
CONTRACTOR INFQRMATON
BUILDING DIVISION PERMIT
�a..
BUILDING ADDRESS:
KNOLL SYSTEM CORP
PERMIT 904.050025
OWNER'S NAME:
PERMIT ISSUE DATE
MARK KOEPPEN
5375 CLAYTON RF)
ONE:
—.OS/04/2004
SANITARY NO. CONTROL NO.
(925)787-5626
ARCHITECTYENGINEER;
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
l= Q Q Q
LICENSED CONTRACTOR'S DECLARATION
Job Description
I tomb, air,. that 1 am licensed under provisions of ces 9 (Commencins
with Section 7IXU)of DlNsion Jof the Busineuand o u ntl veal'Isi
�,�,�I,�°"`andc�F`'•zo I,1C�„
REPLACE FURNACE &ADD A/C
Dark //oma Conuusor
E
ARCHITECTS DECLARATION
DECLARATION
1 understand my plans shall used u public
v
Liccmcd Professional
OWNER-BUILDER DECLARATION
1 hereby ,(Sere Thu I exempt License Law for the
from the Conon
I.S..Bumps
following reason, Coo :
7onstrBusiness and Professions Cook: Any tiny.. county
whet requires rperost re construct,
.trent improve, ticermiitt ri repair any aVuowrt
aplan,pplicant
prior to its issumro,ale requires to ue thevision of for met permitmce ssignet shhmcm
that teescing wJ Purtum,tole) of theeBusinessneem fare Chapter
Sq. F[. Floor Area V lOn
(commencing Sectioor Division Cede) or
of the Business and Professon.
basis
ate pa for
Nn ha is etymps IMrefrom and de buts for dm alleged ewmption. Any vlolallon of
em and the Any
Section 7031.5 by any applicant for a permit objects the applicant to a civil Penalty of
er00
Occupancy Type
not mom than five hundred doubts (5500).
P Y YP
❑ I.uawml of he proprny,wmY emPloycu with wguu then wlc rompenssti.n,
will de, the work and Ne.nnurt isnmimemled or oRertd fonamstc. 7011. Business
and Pmfe.Vmh Cede: The Contractors License Law does not apply us an owner of
Required Inspections
props ny who builds or improves thereon, and who does ouch work himselforthrough his
own employees. provided that such improvements are not intended... flared forssle If.
however, the building or Improvement is old within one year.( completion, the owner
Wilder will tars she burden of proving the, he did not build or improve for purpose of
.101
1. as owner of BIC property, am esclmlvely eomrwling with licensed conOKI.n an
conumcl the prejen (See. 701x. Business and Pre(nssions Cotler) The Commatu 's Li.
cents law doss not apply to an owner of property who builds or improv thereon, and .
who contracts for such projects with a eonuacsos(s) licensed pursuant to the Conusecsors
Lkow Law.
❑ I ren exempt under Seo. ,B&P C for this moon
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penally of perjury one of the following declarations:
I have and will maintain • Catificam ofConwn„o wlfinsurt for Workers Compan-
ss Ion, u provided for by Section 3700 of the labor Code. for the performance of the
work for which this permit is issued.
1 have and will maimain Workers Comperuation Imuran¢, as required by Section
of the labor Code for dm performance of the work for which this permit is issued.
My Worke`rss'C radon Inwrance cariar antl Paltry umbe�ry}r�e p Q
Carrier. `v't'f^� Pollry No.;
CERTIFICATE OF EXEM PnON FROM WORKERS'
COMPENSATION INSURANCE
(Dissection need tette completed If the Per th Is Intent, hundred dollen r$Hi
or less.)
1 cenify that in the performance of the work for which this Permit is issued, 1 shell not
employ any peron in any manner o as an become subject to IM W.rkeri Compema0on
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subjectto the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pesmil shall be deemed rovoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that mom is a construction lending agency for the Performance or
the work run which lets permit is issued (Sec. 3091, Civ. C.)
Lcndcrs Name
Lopear.Acub.
I cenify, that I have read this application and sale than 0. them lammed.n is
Goren. I agree to comply with NI city and county ordinances and into laws relating in
building construction, and hereby authority representatives of this city to enter upon the
ahovcros.judgm propertyfor
purpo
(Wt,) agree to save, indemnify and keep beret the City .f Cupertino against
st and ex penseswhich may in any way ettme asainn said City
awareon which may
inemisleLjudgmemetrai
of me training of Nis per mit.
A
APPLICANT
APPLICANT' ERSTAN S C 1PLY WITH
Issued by: Date
/,WILL
SOURCER ATI
AVON-POINTar
�
/W
Re-roofs
Type of Roof
Signature.(ApplicenUContro� Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building. .Paul nom ear handle bavardme. material
u dcOned by dm Cupertino Municipal Code, Chapter 9.13, and the Health and Safety
'We, Semon 35532(a)?
❑Yns zaw/
All roofs shall be inspected prior to an roofing material beim
P P Y g g installed.
Will the applicant or future building caw or devices which
If a roof is installed without first obtainingan inspection, I agree to remove
P g
mil by the B
nus air contaminants u defined by tiro Bay Arta Air Quality Management
Area Air Qu
all new materials for inspection.
District?
DisuicR
C] Yes
1 have mad Ne haramsms materials requirements under Chapter 6,95 of the Califor.
ria Health & Safety Cade, Scctiom 25505, 25533 and 25534.1 understand dw if the building
Jmal not cu ecu, Y ho a tenant, Thu it u I puns.111.ky on notify sic octup ro of he
regmramenis hm nb;m.t n ,or. fmcalcafOccpnyey
Signature of Applicant Dale
5l4)0�p
All roof coverings to be Class "B" or better
Owner am .rived ogcm Duc
aClOF
UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS/o 3 d 3 /L,.a —
PERMIT # 6 y�
OWNER'S NAME:
PHONE # Siof - q
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors: a
Signature Date
Please check applicable subcontractors and complete the followine information:
--B,
O,kner/ Signature
*0`o 4
Date
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
--B,
O,kner/ Signature
*0`o 4
Date
CITY OF
• CUPERTINO
Is
•
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
APN #
Date:
Building Address:
1 BREMFURN
!0 3 n• -
MECHANICAL
Owner's N me: Q
wNC
Phone #:
S/o - 3o) - 9s q u
Contractor: Phone:
License #:
92-5 6F/-oy-1
78 µ 3,41
Contact: jaw n hone: p _
Cupertino Business License #:
ELECTRICAL
BSEISMICRE
Building Permit Info:
BUILDING
Bldg ❑ Elect Plumb
Mech
Job D cri tion:
1 MPERMITFEE
Q4U - cr. A- cn31an
- 3o 6M
Residential Commercial ❑
Plumbing Permit Issue
For Residential Installations:
BPERMFEE
Attic ❑ 151 floor ❑ 2nd floor ❑
BUILDING
Adhere to min set back requirement ❑
—Bldg
Plan Check Fee
For Commercial Installations:
BUSLIC
Replacement same weight ❑ Additional weight (structural calcs) ❑
BUILDING
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction:
Occupancy group:
YL5V - ff D
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable
Fee ID
Fer ilrcrrintinn
1 BENERGY
Energy
BUILDING
1 BREMFURN
Relocation of Furnace
MECHANICAL
1 BREMACOVER
A/C Unit> 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <=.10, 000 cfm
MECHANICAL
I BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
1 MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMII'FEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Permit Fees
BUILDING
BPLANCHK
—Bldg
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING