05120061 CITY OF CUPERTINO °�€^: >g '^ `" '£ "
1 BUILDING DIVISION PERMIT CC1�l�fi, =R�.C�T�UR�XI�4RM�'�Y6�.k
BUILDING ADDRESS: HUSSEY BROS INC PERMIT 140.0 5120061
20233 NORTHCOVE SO
OWNER'S NAME: PERMIT ISSUE DATE
ig 1h MARIA IPSARO 640 TAYLOR AVE 12/13/2005
NE: SANITARY NO. CONTROL NO.
(408) 733-6360
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BO EO PLUMB MECH
O
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
booby afumn Net 1 am licensed under provisions of Chapmr 9(commencing
wllh SmUon7OW)0(Divtsion3orawnusin mdprofessium Cod andmylicemch
n infullfenceandeffea. REPLACE FURNACE
j02 Llcenmcless LIe.4
Dam 1 understand my plana shall hene d As public records
5 3 Licensed Professional
OWNER-BUILDER DECLARATION
.� 1 hereby affirm that I am exempt from be Comrscmrs License Law for the
0 o following mason.(Section 7131.5,Business and professions Cade:Any city or county
i$ which requires a permit to construct,elm,.Improve,demolish.or repair any structure $2600
prior W its iauance,also requires the applicant for such pereliva role a signed smtenclu
q C that he I,licensed pursuant in Mepmvisiomnfthe Connector's UcemeLaw(Chapter 9 Sq.Ft. Floor Area Valuation .
y (commencing with Section 70110)of Division 3 of the Business and Predications Code)or
$ that he is exempt therefrom and the basis fm the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit Objects Oe applicant in a civil penalty of J AP14 NVAYer U u Occupancy Type
not more than Eve hundred dollars(5500).
❑1,As owner of the property.or my employees with wages As Weir Ole campewlinn,
will do the work.and teswaum canal intended or offered farsh(Sec.7044,Bushel Required Inspections
and Professions Code:The Convector's License Law doe,not apply m an owner of q P
property who builds cr improve,Mercer.and wine does such work himself e,through his
own employees,provided tat such improvements Are not intended aroffered f Bale.If.
however.the building or Improvement is Old within one year of comped..We owocr-
builder will have to burden of proving that he did sal Wild or Improve for purpose of
ale.).
❑1.as owner of the property.am exclusively canuacling with licensed contractor m
construct the project(Sec.7014,Business and professions Cade:)The Commumar'a U.
came Law does not apply 0 an owner of propeny.who build,or Improves theman,and,
who conu ons for such projects with a contractor(s)Eurued pursuant W to Convectors
License law.
❑Iamexemptundef Sec ,68,PCforthi,maon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pedone of tc fallowing declantiom:
1 haveand will maintains C,,dI ofcomenuo xelf-insum ferweakees Coot
saran,As provided for by Section 3700 of the Labor Code,for the performmm of the
wads for which this permit is fared.
❑1 have and will maintain Workers Compensation Insurance.as required by Section
3700 of the labor Cade,for to performance of the work forwhich this permit is Issued.
My Worker,Compensation Insurance cart.cr and Policy
numocr am:
Cerner. 0 . O .MPolicy No,: I*RTA � IIONFROMWOR RS
COMPENSATION INSURANCE
missection nerd notbecompleted iftle permit is foram hundred dollars($100)
or less.)
I anify that In the performance of the work for which this permit is laved,l shall not
employ any person in any manner an As in become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.IL after making this Certificsm of Exemption,you should
become subject to the Worker's Come sensation provisions of the Labor Code.you must
.,Z forthwith comply with such provisions or this permll Well be doomed evoked.
r O CONSTRUCTION LENDING AGENCY
[—t (hereby aff,m that then is aconstruethn lending agency for the pelf urmancauf
W> the work for which this permit I,issued(Sec.3097,Civ.C3
WM Q Lenders Name
z Lender's Address
U Q I certify that 1 have read this application and sum that the above information Is
V,H correct.l agree to comply with all city and county ordinances and state laws relating W
O U Wildingcow ction.mdhembyauthoro<mpmse Wives oftiscity to enter upon led
X121 abovc-menlioned property for inspection purpose
(We)Agee O sere,indemnify and keep h less the City of Cu no against
y Iiabilivesjudgments. dexpenOs ichm In any azfislacialy
to U APPconsequence
CAannceUNDER ANDS Aof N MPLY WITH ALL NON-POI T Issued by: Date L ?r -�
SOURCE TIONS.
Re-roofs
Signance of AfflMoMobald
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle harardaa material
As defined by to Cupertino Municipal Code.Chapter 9.12,and be Health and Safety
ode,Section 255320)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes ,ef Na
Will the applicant or future Wilding occupant ac cgvipmenl Of devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
It heardosl air contrNnants a defined by the Bay Area Air Quality Management all new materials for inspection.
istric17
❑Yea faMG
I m ehaakaus materials rcyuircmcnu under Chapter 6.95 oft,Califon
nia He &S IyCode,Scctiam 25 .25533anti5534.1understaedthenifto Wilding
Java al cu ntly haw A come, is my=possibility m notify the occupan f the
sort
them
wissuanceoraCertifmateofOccas�`' Signature of Applicant Date
q '�"3 All roof coverings to be Class"B"or better
Owner or eWhomn0 agent D e
Community Development
10300 Torre Avenue
aCIF
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
OUPEkTINO
Building Department
JOB ADDRESS: PERMIT#
233 v 6611
OWNER'S NAME: H612AP PHONE # -2—q--
GENERAL
GENERAL CONTRACTOR: FAX#
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
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet
T
/Co act alure 15ate
f
CITY OF CUPERTINO /
u CITY
**CUPEI,TINO PERMIT APPLICATION FORM
APN # 3 /6 i// 0J l Date:
Building Address: —/
33
Owner's Name: Phone#:
fkU P S rt�a sem- g 477 2
Contractor: 1 ` Phon License#:
Kvssc �6�05 Ka8 73�6�C� (�7566
Contact: Phon . Cupertino Business License#:
t Sse yob 733- 360
Building Permit Info:
Bldg a Elect V9— Plumb -9 Mech E5
Job Description:
L 4,s1 2
Residential Commercial ❑
For Residential Int lations:
Attic ❑ 151 floor 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
e>C,-) Ir
Strapped ❑ On PlatformBonded ElSq.Ft. Floor Area:
New Location ElReplacement*
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING