04040038 CITY OF CUPERTINO .�}� �gU'�"' �''z
If BUILDING DIVISION PERMIT 0'N P* CT61 ANFO '^
BUILDING ADDRESS: AAA FURNACE & AIR CONDITI PIT6004040038
OWNER'S NAME: PERMIT ISSUE DATE
HELGA H
NE: SANITARY NWT O OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
sero LICENSED CONTRACTOR'S DECLARATION Job DCScflphOn qR�!;An,e1 �g ■ t�
1 hereby affirm that 1 am licensed antler previsions of Chapter 9(commencing F1 plM{[�I,pf =
ii with Section 7")afDNW.O3of tho Business and Profestons Code.and my license is .`AILY'"'sk6'm 1Y�maa
=re In full fora an 6 S) REPLACE FURNACE & ADD A/C
Lkenu I - CLie. �2onnector 07 eg APR 2$ 2004
Y
Data
17S DEC
Y an CHITECI'B DEC
I undemmnJ my plans shall M used u public rocarJs
3 Licensed Professional
BUILDING
OWNER-BUILDER DECLARATION
I hereby.(Bent on 1 am exempt from the Commutes Cm License Law for the
En O following Terson.(Section 7113 L5,Business and wn,de Professions Cale:Any city m roomy
which requires a issuance,also W aims t e,alter.improve,h lmmit t m e a sig any tWment
F�< clum
prior Witsensedppursuant
aroquiroe pro inion of for wchpator'WimnsO Law statement
D
quit
wase. lira;withSWMI7odie pmviAtick.fthe ftheBuaoemmi¢nselew(Codc)., Sq.F[.Floor Area Valuatio
$ that he sexemithomion70ndthe iaikion3 don alleged
Professions Code)ser
Net he is exempt therefrom and the bock for the alleges eumption.Any violation of veno �ASw A
Section 7031.5 by any applicant for a permit subjects the applicant W a civil penalty of 3 t+se Ig !NWheI O O Occupancy Type
not more Wes five hundred delta.(5500}
Q I,a owner ofnm property.army employees with wages m their sok compensation,
willdo the work and theswctuu is notimm�dad.,offered forale(Sec.7044,Business
and Profession,Code:The Conuactoes License Law does nut apply 10 an Owner of Required Inspections
property who builds w improves thereon.and who does ouch work himself m through his
own employees,provided that such improvements are not intended oraQered for sale,if,
however,the building or improvement is old within one year of completion,the owner. ,
builder will have tho burden of proving that he did not build or improve for purpose of
sale.).
Q 1.as owner of the property,am exclusively connneing with licensed worm rs to
construct 0m project(See.70/4,Business and Professions Cade:)The Connector's Li.
cense Law dors not apply W an owner of property who builds or improves Nemon,and
who contracts fm such pmjec%with a conuuur(s)licensed pursuant ro the Contracmfs
License Law.
❑I.C.emptunder Sec. ,B&PCforthbreaon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
I have and will maintain aConiBcae ofConunt to Self-inswe for WorkefsCompen-
i.i...a provided far by Section 3700 of the labor Cade,far the performs..of the
fk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,ss required by Section
of Inc labor Code.for the performance of the work for which this permit k lamed.
yWorloh` mpumation Insurance anise and Policy number are: ��{��j
Grtier: Policy No.: X91
R 1 C OF EXEMPTION PROMW R
COMPENSATION INSURANCE
(Th6 section raced not he complemJ if the permit U for enc hundred dollen(SIM)
Or kaJ
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manneru he to become subject to the Workers'Compensation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making thin Certificate of Exemption.you rhuuld
become subject to the Women's Compensation provinces of the Labor Code,you must
Q Q forthwith comply with such provisions Or this permit shad he deemed revoked.
z tiCONSTRUCTION LENDING AGENCY
[.. 1 hereby alarm that there i,a Construction lending agcnry fm the performance of
lY the work for which Nu permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Add.
U I certify that 1 have road this application and stale that the above information is
W Fcomact.I agree to comply with all city and county ordinances and sum laws minting W
building construction,and hereby authorise representatives a(this city W enter upon the
fA above-momioncd property for inspection purposes.
(We)agree W ave,indemnify and keep harmless Jur City of Cupertino against
W) liabilities,Judgments,costs and expenses which may in any way accrue against aid City
U Z in consequence of the granting of this permit.
f+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO EREGULA77 S.
D -b7 o Re-roofs
Ignuure of Appliant(Conuact Dele
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliaut or future Wilding occupant store or handle haeardous material
as defirted by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
otic,Sc zss3zea)a
Qy. All roofs shall be inspected prior to any roofing material being installed.
Ya J�tu
Will the applicant or future building occupant use equipment or Jcvica which If a roof is installed without first obtaining an inspection,I agree to remove
mit ImOwdous air cmemmimime as defined by the Bay Am.Air Quality Management all new materials for inspection.
District?
Q Yes
I have read the harmak smamdalsrequiremontsunderChapmrA950fdenCalifor-
nioHcalm&SawyCode,Scnons8505.25533 and 25534.1 understand Ihatifthe building
Joss not currently how a knant,that it is my responsibility to notify the arouput n(the
myui menu which must he MCI)MOT WiauanccOf aCertificate of OCC ry. Signature of Applicant Date
n ', ��d All roof coverings to be Class"B"or better
war amhanrcd,gem to
Community Development
10300 Torre Avenue
__4 Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERM�T # ��
oVo,C7/I C FfT 3
OWNER'S NAME: PHONE #
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 Rock
/Tjile /
Owner/Contractor Signature Date
aimoz,
CITY OF CUPERTINO
FURNACE/AC
ST
OF
UPERINO PERMIT APPLICATION FORM
APN# _ Date:
Building Address: s/ _
9,,�7q
Owner's Name: Phone #:
- LG A Z-4 — YJ4:5/16b
Contractor: Phone: License #:
4a C --)r,
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
c an e, 4111.4cu FD 14a 47v cJ
Residential Z Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"d floor❑
dhere to min set back requirement❑
IFFor Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installationTlanning Approval Re uired,❑ .
Cost of Project: Type of Con cti Occ ancy
El p:
Strapped ❑ On Platform onded Sq.F . ea:
New Location ❑ Replacement ❑
Qty. '.f
A is 1 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Licens BUILDING