04060061 5 CITY OF CUPERT O `
BUILOING DIVISION PERMIT 'X-0N'T"`GT0Rj,144,�OR AT 0 , y',
euaor"c ADDRESS: .VALLEY HEATING & COOLING """'04060061OWNER'S NAME: PERMIT ISSUE DATE
RICH RANDOLPH N 4 TH ST
NE: SANITARY NO. CONTROL NO.
(408) 294-6290
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
a O p LICENSED CONTRACTOR'S DECLARATION
F 1 hereby afnnn that I am licensed under previsions of Chapter 9(commencing `� Job Description
zpej wiNllfaren 7")of Division 3otum Buein and Protcsamne Codc,and mylicenw is RF� ��1 ®& ADD A/C'
n< full forte
If
r
Liccnw I LIC
Da Cuntr
AI'gD RATION
dc
unrwnJ pl An sh ah Ise he s public records
;8t; License) n3 .I' NOV a 2004 `
S OWNER-BUILDER DECLARATION
.<4 by affirm that I am exempt(rum Ne Contractor's License Law for the
E:DO O following mason.(Section 7031.5,Busimu and Profe siuns Cade:Any city m county
m which requires a Permit to convrect,alter.improve,demolish.or mpairiny A n um
Zi prions itsissuer,alsorequims the applicant forsuch permitho tilt a signet smtamcnt 990
£ss< that he is licensed pursuant to the provisiomnnf the Contractuh License Law(ChapmrY O Valuation
yFa (commencing with Section 7")of Division 3 of Nc Business and Professions Code)or
that he it exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of 3 NfNeliiihberO 0 Occupancy e
not mom One five hundred dollars($500). P Y ZYP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will de the work.and NesWctam is net Intended er.ROmd far aale(Sec.7044,Business Required Inspections
and Professions Code:The Connector's License Law does oat apply N an owner of q p
property who builds or improves thereon,end who does such work hi mol f a r through his
own employees,provided that such improvements an not intended or offered for sale.If,
however,the Wilding or improvement is mold within one you of completion,the owner.
Wilder will have the human of proving that he did not Wild or improve for purpose of
sale.).
0 h as owner of the property,am exclusively connoting with licensed Wron cors to
construct the pmjcct(Sec.7094,Business and Professions Code:)The Contractor's Li
come law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant m the Contrctors
License Law.
❑1 am exempt under Scc. .B @ P C for this mown
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby of ron under Penalty of perjury one of the following declarations:
I ham and will maintain aCcrtiftcau of Cement to self-inwm for Warker'.Compcn-
motion,as provided for by Section 37110 of the labor Code,fm On performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance.as required by Suction
3700 of the labor Cod,for the performance of me work for which this permit is issued.
My Worker^ mpensalio Inwmnec caviar And Policy nu ere c:
Ca 'ere:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need sol W complmed if the pcnitisforanc hundred dollars(5100)
or[ass)
I cenify Out in the performance of me work for which this permit u issued,I shall not
employ any Person in say manner an as m become subject to the Workers'Compemadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cemftcate of Exemption,you should
become subject 0 On Worker's Compensation provisions of the Labor Code,you must
0 Z forthwith comply with such prvisiens or Nis permit shall be dccmed mvoked.
,'Z.aO
CONSTRUCTION LENDING AGENCY
[—ice Iherehyelfom that there is a consuuctinn lending agency for the performance of
Q! the work for which this penis is issued(Sec.3097,Ci,C.)
W�Q Lenders Name -
z lender's Address
U 0 T certify that I have read this application and sate that the above information is
E' const I agree to comply with all city and county ordinances and sem laws relating to
0 U Wilding consuuction,and hereby authorlae repmsenutives of this city to enter upon the
a
above mentioned Properly for inspection PUqmSCS.
(We)Agra r save,indemnify And keep hanlcss On City of Cupertino against
aF"yZ liabilities,judgments,of
wang of this Permit. may in any way accrue against mid City
U z A consequence of the UNDERSTANDS
of Nis permit.
a.o APPLICANT UNDERSTANDg AND COMPLY WIT!r ,NON-POINT Issued by: Dale
(SOURCE REGOLATAOC� `�
r rh Re-roofs
Signator pl' tAZ ctor Dau -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
/Will the a CuPen or future building k,Chapter
emm or handle Health and
material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health enJ gaiety
Je.Section 25532(e)?
[I Yes All roofs shall be inspected prior to any roofing material being installed.
No
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 haardous air contaminants as definnd by We Bay Arca Air Quality Management all new materials for inspection.
Diwicrf
E]Yen
I have mad the hasaMnus materials requirements under Chapter 6.95 of the Califor-
AinHot lth&Safety Code,Sections 25515,25533 and 25534.1 undcrsund Nat if the Wilding
gCos not curmody have a tenant that it is my responsibility to notify the occupant of the
'rtmenu whir, must W et pd issuance of a Certificate of Occupancy.
Signature of Applicant Date
owmr eat ori, age , Date All roof coverings to be Class"B"or better
..�.., Community Development
10300 Torre Avenue
+ � Cupertino CA 95014
Telephone(408)777-3228
CIN OF Fax(408)777-3333
UPERTINO
Building Department
JOB ADDRESS: PERMIT # U
D2s•� �.� � 5 ,
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: , I FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontra tors 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
P�Aqer/C ntractor Signature Date
r
• CITY OF CUPERTINO l
FURNACE/AC
,CUPEkTINo PERMIT APPLICATION FORM
APN# � / 3 0 3 Date:
Building Ad,Cd'fess:
(d Yl S� �!d G S GQaQyY�
Own 's N g
r, 9 X10/' LI PI U
0 v
C ((tv ' Phone:/ �� � , Z 2.dd
Contac Pho Cupertino
viness License #:
W10 tJtA1C-K0l
Building Permit Info:
Bldg Elect Plumb ❑ Mech
Job escription.
voa cti veep/ 70K ATG[ .4-10, add a�.i C-7�4-7.
Residential IZCommercial ❑
For Rgg��idential In tallations:
Attic LJ 1st floor Ll 2"d 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: v l) 09 Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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
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 License BUILDING
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