05090097 CITY OF CUPERTINOsa ��^ Fa o '• ^'k d" r'
BUILDING DIVISION PERMIT kCONTRACTC)RINFA
�ORMTION
BUILDING ADDRESS: PAYNE HTG A/C PERMIT N0.05090097
20122 NORTHCREST SO
OWNER'S NAME: PERMIT ISSUE DATE
Ak ANNE MITCHELL 2045 STONE AVE _Q9/14/2005
ONE: SANITARY NO. CONTROL NO.
(408) 294-8957
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� t� 0 Q
00, LICENSED CONTRACTOR'S DECLARATION b-:a j j--"
F I hereby affim than 1 am licensed under Pmvivans of CMpter 9(commencing lob Deseripholl (� A_1 II hQ I
i`uf with Section 7000)of Division 3 ofbC Business and Pmfessiaru Code.and my license is
n<n, in full fomeand effect �J ,k'''d
�y q REPLACE FURNACE, ADD A/C
otsore ess comarmmr
011
� e I n&..d my plans hal he used as publics cm '-^� / 2005
JyU
s LLo Lecnud Pmressional I a
3 OWNER-BUILDER DECLARATION [yI I� 1
f 1 hereby affirm That 1 am exempt from the Contramori License Law for IW B1 :1 I L5
t.2 O following reason.(Section 7031.5.Business and professions Code:Any city m county BBB®BYYY"`���5/iii111 LLL���...111
5- which recums a permit to construct.alter,urr m e.demolish.or repair my mueture 4 713
prim of its issuance,also requires the applicant for such permit in file a signed samncat
that W is licensed purmint m pa O
Ne mvisiof the Comment's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
'l-el (commencing with Section 70016 of Division J of thc Business and Profrsiom Code)or
- that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant an a civil penalty of
not mart than five hundred dollars(5500), -3 April T U Occupancy Type
0 1,as owner of the property,on my employees with wages as their sole compensation,
will do Newark,and the mmture is not intended or offered finale(Sec.7044,Business
ad Profevtioa Cade:The CantrmmYs License law does Out apply to an owner of Required Inspections
property who builds minifimms thereon,end who doea mchumichimself or through his
Own employees,provided nonsuch improvements are not intended oraRercd forms,If.
however.the Wilding ar improvement is to within one year of wmpleuon,He owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property am exclusively contracting with licensed contraction;to
construct the pmject(Sec.](Ia4,Business and Professions Code:)The Contractor's Li.
cense Law docs not apply to an owner of property who Wilds or improves Hereon,and.
who contracts for such pmjeeu with a eonuacto(s)licensed pursuant or he Conmemh
License Law.
❑1 am exempt under Sec. ,B&P C for this rrason
IC311),
ner Due
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of He following dcelmaBmu:
1 haw and will munuin aCenifiaus of Consent ro self-insure far WorkeYsCooper.
ion,a provided for by Section 3700 of the labor Code,for the perfomance of tbe
rk for which His permit is issued.
1 have and will maintain Wmkels Compensation Iosurma,u required by Section
of He Labor Code,for the peKormanee ofthe work fm which this permit is issued.
Worker's Compensation Insurance ania and Polity number art:
nicr._5Nl-LQ CcMn Policy Na.: L-7 Z q�- Z
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is forme hundred dollars($IIID)
or less.)
I certify Nat in the perfmmanec of the work for which this permit B issued,I shall not
employ any person in my mmner m as or became subject to the Workeri Campenamon
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT.If,after making this Cci ifiam Of Exemption.you Amid
become subject in He Worker's Compensation provisions of He labor Cod,you mum
.J ,Z foMwith comply with such provisions or His permit shall W deemed evoked.
Z O - CONSTRUCTION LENDING AGENCY
E-' l hereby alfnm had Here is a convection lending agency for the performance of
ai He work or which this permit is issued(Sec.3197.Civ.C.)
a0 Lender's Name
z Lenders Address
U Q 1 cenify Hat 1 have rad this application and some that the above infonmmin,is
P coma I agree to comply with all city and county atdinaam and mule laws relating W
p V building convection,and hereby autumnropresenstims of this city to enter upon He
a Ww-mcnumuldgm property(m is fa c mat puryases
F y (We)agree to save,indemnify and keep harmless the City of Cupertino against
(n ins.
ofth,costsand eapmtsesmit, may in any way seems against said City
fJ z A APPLICANT
of the greening of His permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE Date y/ 6f-6 d--
REGULATION Cl
_fic 4—[t.f bq Re-roofs _f:1., VL
Sngnuurc err Ap manUContrmtor
HAZARDOUS MATTERIALS DISCLOSURE Date Type of Roof
Will He applicant or future Wilding occupant wort or handle ha moa material
Alku defined by He Cupertino Municipal Code,Chapter 9.13,and the Heald and Safety
otic,pYu 25512(x)? All roofs shall be inspected prior to any roofing material being installed.
7Will the appliesm or future building necupmt use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hard as air consmimns u defined by On,Bay Area Air Quality Management all new materials for inspection.
uicn
❑Yea B
I have read the h ousbims materials mquimmens under Chapmf 6.95 of the Califm-
-1-HeilH&Safely Code,Sections 25505,25533and 25534.1 undersmu Hmifdc Wilding
se net cl mmly have a tenant.dant it o my rtspensihility m nod y the occupant Of the
ui cuwhich most beret prior to issuance or a Comilale of Occupancy. Signature of Applicant Date
owner or aulhori&agent Date All roof coverings to be Class 'B"or better
t, Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
coo,
Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
2ot22 , � QSlb�oo � 7
OWNER'SNAME: (uAt,,r PHONE 4� Z'�q_-8c},S-7
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: �� o 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
Tile
Owner/Contractor Si tune Date
CITY OF CUPERTINO g
` , FURNACE/AC
CUPERTINO PERNUT APPLICATION FORM
APN# �,/ / 3 � Date:
b `' `� -13-os
Building Address:
2o122 " Ceesl SQ�Q2�
Owner's Name: Phone#:
kc"1 l
408- 29 1-9 5
Contractor. License#:
PA iw)b- S 0-3 9
Contact: Cupertino Business License#:
M 6,ez t< PA rJ-c
Building Permit Info:
Bldg ❑ Elect Im Plumb ❑ Mech
Job Description:
o AAA Me—
Residential K Commercial ❑
For Residential Installations:
Attic ❑ 1" floor §& 2°d floor❑
Adhere to min set back requirement[�r,
For Commereial Instanations:
Replacement same weight ❑ Additional weight(structural calcs)❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required []
Cost of Project: o� Type of Construction: _ P�cY yup:
Stepped y '1 i On Platform �L S i M F,pm.
Bonded Sq.Ft.Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
P
BSN BUILDING
Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit>10,000 cfm MECHANICAL
BREMECE1V T 1 A/C Units<40,000 cfm MECHANICAL
B , itch&Outlets ELECTRICAL
BS EMRECEPELSMICRE e. SwSeismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance
MPERMITFEE Mech Permit Issuance ELECTRICAL
PPERMITFEE NHToing Permit IssueMECHANICAL
Bid Permit Fees
BPERMFEE PLUMBING
BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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