04020071 CITY OF CUPERTINO
BUILDING DIVISION PERMITCO AACTOU INFOR'MAT ON- ,'.
BUILDING ADDRESS: A Sr H HEATING PERMIT NO.04020071
OW NER'S NAME: PERMIT ISSUE DATE
TIMOTHY
NE: SANITARYNO. CONTROL NO.
(408) 279-n722 In
HITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ep o 0 0 0
LICENSED CONfRd underS DECLARATION
t1 hereby aflirtn Ihel 1 xm lianxd under provivons of Chepmr 9(commencing Job D tion
� Section 70f0)ofDiNxion 3efNc Buaincxxand Professions Code,andmygctnsch;
CP REPLACE FURNACE v4cense Class _ Lin.N
^ Dem ContractorDEC
As shall use DECLARATI
ON—
U 1 undcrsund my plans shall be used as public rtrnrth / q
30555 Licensed Professional ?�04
5OWNER-BUILDER DECLARATION '
1 hemhy.,.Net 1 am exempt from Ne Contractor's License Law for the
Ra O following reason.(Section 7W 1.5,Business and Profession Code:Any city or county 'Y
?t which requires a permit 10 tonNucl,alter.Improve,demolish,or Minch any SWcruro
Fly prior as its issuance.also requires the applicant for such permit to file a signed statement
P < Ihalheislicensed pursuammficpmvisionsoftheConlmemr's License Lna(Chepter9 Sq. Ft. Floor Area Valuation
yz❑� (commencingwith Section 7000)of Division 3 ofthe Businessand Pmrcuinns Cwc)or
3^
that he is exempt Nemfmm and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant forapermit aubjecu Ne applicant to a civil penalty of 31 DT�IDImIb&YO Occupancy not mom Nan live hundred dollars(SSW). P y Type
0 1,as owner of the property,or my employees with wages as Nair sole compensation,
will do the work,and Ne awmum is not inmaded or offered for sale(3x.7044,Business
and Professions Code,The Conuacme.License law does not apply to an owner of Required Inspections
property who builds m i reproves thereon,end wh.does ouch work himsel f or through his
own employees,provided tharauch improvements am not intended.tottered forule.If.
however,Ne building or improvement is said within one year of completion.Ne owner-
builder will have Ne burden of proving that he did not build.r improve for purpose of
.101
0 I,as owner of the pmpeny,am exclusively connecting with licensed continents in
consumer the project(Sec.7044,Business And Profrrsiotu Cade:)The Co=ox's U.
cove law does not apply to an owner of property who builds or Improves Berton,and
who contracts for such projects with acorawtor(s)licensed pursuant to Oe Comtscloes
License Law.
O l am exempt under Sm ,B&P C for this mason
Owner Data
WORKERS COMPENSTnON DECLARATION
1 hereby affirm under penally of perjury one of Ne following declarations:
I have and will maintain a Certificate of Co®enl to wif-insum for Workers Compcn. -
ution,u pmvidcd for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
QI have and will maintain Worker's Compensation Insurance,as required by Section
"I of the labor Code.for the performenec of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am::'
Cartier. I gGl.(GIL I IU S Policy No.:u fQ t"7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This rection need not w completed if the permil is intone hundred&&ars($100)
or labs.)
I cenify that in Ne performance of the work for which this permit u issued.l shall not
employ any person in any mannersn a[to become subject to 0m Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject n the Workers Compensation previsions of the Labor Code,you mon
Cr Z forthwith comply with such pmvisin.s car this permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-i 4 I Wreby.M.that Me.ire enamored..kmfing agency far the mrommncc of
as > tht work fur which this pemtil is issued(Sec.3099,Civ.C.)
WM Q LA.der's Name
7,z Lcnder's Address
UQ I certify that I have read this application and sum that the show information is
;^ carted.1 agree n comply with all city and county ordinances and state laws relating n
Q SV^ building eonswnion,and hereby aumorim representatives of this city to enter upon Ne {
H Gshove-mmliwad property for insisted..proposes
(We,)agree to an.indemnify and keep harmless the City of Cupertino against
pat f/j habilides.judgments,costs and expenses which may in any Way acerae against said City
U Z in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOURCE REGULATIONS. , e ,,,a�
I .7 ^'. 4-.." LKS-L-1a-04
more. Appsn"urx mcmr Dates Re-roofs
HAZARDOUS MATERIARE Type of Roof
Will the applicants future building occupanumm rah t.uha havue.us material
az dcOntd by the Cupertino Municipal Coda,Chapter 9.12,and Ne,Health and Safety -
odc,section 25532(a)?
OyutS. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havardous air contaminants az defined by Ne Bay Area Air Quality Management all new materials for inspection.
Disuicr?
CYts CME
1 have mad me hsaaMnuamaterielsrtquiromtnu under Chapwr6.95 ofthe Califor.
nia Hcalth&SafclyCodc.Sxtioos2 505.25533 and 25534.1 undersand Nm if Ole building
does not currently have a tenant,thin it is my msponsibilily m notify the occupant Of Ne '
rcyui rats which meal be met n'ssuancc oft CcniRcae of Occupancy. Signature Of Applicant Date
Z-10—
OwnerurauNodredagent Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO
IE 1,
FURNACE /AC
CUPEYTINO PERMIT RMIT APPLICATION FORM
APN # _ 3 ! Date:
Building Address: d s
Owner's Name: � t Phone #: gg IR _ 784
Contractor: - &- License #:3o
Contact: Phone #:
ALE PAELPC
Applicant/Contr
actor
.
NCv G
Building Permit Info:
Bldo Elect Plumb ech
criptio ---
ntia Commercial:
Sq.Ft. oor Area: $/Sq,.Ft.:
Architect/Engineer: Valuatioi
Type of Constniction: Occupancy Group:
Qty. if
A licable Fee ID Fee Descri tion Fee Group
BENERGY Energy �BUILI]?NG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm [ MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPI' Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILD-)NG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Nlech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg PermitFees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License _ 13UI1-1DN6
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