04050130" ' r CITY OF CUPERTINO C� ,^ , .^��*I ,'.`' �WT,IO'N,a
suamrvcDrvlsroN PERMIT , : a "-x
•
BUILDING A PERFECT CLIMATE PERMITNOO4'OSO13O
-
110975 N PERMIT ISSUE DATE
OWNER'S NAME:
KRISTEN YAMASAKI 10570 S DE
BE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITfiCf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRd..do,S DECLAAAA... ATIONof
Job DeSCit[IQ�TN�
UM M 1 Nrcby affirm that 1 mm licensed under provisions of Chapter 9(commencing lJ:ar
with Section 70KKB of Division 3 of the Real. it Professions Codc,and my license is
LED
inmBmroean e Za> 5 REPLACE FURNACE & ADD A/
j License ass Lk.p
�h,p Dem TSDEor NO,/ yip �t00
qq 7W CHITECTS OECLA ATION Gt".y` Y V y [
? 6
In extend my plans shall hu e used Public ranNs
;o Licensed ProlmaTonal BUILDING
OWNER-BUILDER DECLARATION
E<f 1 hereby,(Oran that 11. uusin from the Contmcwr's License Law for the
1OO following reason, hermit In
70n LA Business and Improve,
umoi Code:Any city structure
$r which requires a permit to cnnumct.elwG Npmre,demnllsh,or repair any xwcmm
—zYprior to its issuance.also requires the applicant forsuch permit w file a signed statement
< Nm he is licensed pendanunrhe provisions Ofth.Cont..tor'sLlcenseLaw(Chapter9 Sq.F[. Floor Area Valuation
s (commencing with Section 7")of Division 3 of the Business and Professions C-Me)or
y 3$ that he Is exempt Ncrtrrom and Bre basis for the alleged exemption.My violation of
Section 7031,5 by any applicant for a permit subjects the applicant t0 a civil penalty of 3 14MQ4WrZer0 0 Occupancy Type
Out more Nen five hundred della.WWI. -
❑1,As owner of the property,in my employees with wages As 1Nlr sole compensnlon,
will da the work and the structure is not intended A, ffmd foraale(S.C.7044,Business Required Inspections
and Professions Cade:The,Continuities License raw does ant apply m ns an owner of 9 P
property whobufldsorimproves thercan.andwho doessuch work himselfor Waugh his
awn employees,provicAd that such improvements arc not intended oroffmcd formle.If,
however,Ne building or improvement is sold within ane year ormeapledon,Ne owner
Wilder will have dm burden of Proving that N did ant build or improv:for purpose of
sathJ.
❑1,as owner of the properly,am exclusively contracting with licensed conuacmrs to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Lh
cense law does not apply in an owner of properly who builds or improve trema.,and,
who contracts far such projects with a conVactaKq licensed pursuant in the Contractors
Lion,an Law.
❑l ten exempt..it.,Sec. ,B&PC for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne fallowing declmmlmo:
1 have and will maintain a CcnfOmw afCommut to self-insure for Wmker'sCompen-
1c,
on,as provided for by Section 3700 of the labor Code,far the performance of Nc
rk for which this permit is issued.
1 have and will maintain Workces Compensation Insurance,as required by Section
W of Ne Labor Code,for Ne performance of Ne work for which Nis permit is based.
WorkersCompensadonlnsunncecarfermdPolirynum rem:rtier. �� Q Polity Na.:
CERTIFICATE OF E% Pr10N FROM WO ERS'
COMPENSATI NINSURANCE
(Tab ruction need not In,completed if the permit Is for one hundred dollars(SI W)
Or less)
I cenffy that in the performance of the work for which this permit is issued.l shall not
employ any Person in any manner an a At become subject to the Wmkers'ComPensaWn
I.-of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to to Workers Compensation provisions of the labor Code,you must
0 forthwith comply with such provisions or this Permit shall he deemed mvnked.
z„► CONSTRUCTION LENDING AGENCY
I hereby affirm That there is a construction lending agency for the performance of
p: 7 Ne work for which this permit is issued(Sec.3097,Ci,C.)
aQ Lender's Nam.
z Lenders Address
U 0 I certify that I have red this eppli.d..and slaw that the above infAonA I.la
{s. correct 1 agree to comply with all city and county ordinances and state laws totaling to
�U building construction,and hereby auhorim representatives of this city to cnwr upon the
4t7 above-mentioned propcny for impaction purposes.
4 (We)Agree in anve,indemnify and cp harmless the City of Calendar)against
y liabilities,judgments,cousmdeapense h hmay in any way acerae against mid City
U Z in consequence of fee granting of Nis i.
r"' LICAN UNDEgg&&T is AN W L COMPLY WITH ALL NON-POINT Issued by: Date
0 R ER ULAZolq C-(�-0q
64- Vwmvj(�l Re-roofs
Ugaliture of ApPlicuNCont.emr Date
HAZARDOUS MATE RIALS DIS H Type of Roof (/ J
Willy t applicant Cupertino
future Municipal
nine.Cpanlno or hand Health and Safe
e defined by the Cupertino Municipel'Codd.Chapter 9.2.an c Health and Safety
,lingode,Section 25532(.)?
❑Yns -�❑Na 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
mit havardous eircenwminants in defio.d by the Bay Arca Air Quality Management all new materials for inspection.
Diurict? I
❑Yes _ON.
Ihay.madtheNmrdoosmatedalsm unumcnts under Chapter 6.95ofthe Califor-
niaHcalth&Safely Cade,SecWm15505.2 and25534.1undersmndlhmifthchuilding
dors nor cure try have A moan at it n y reapend0ity to n�dfy due ocapant.r N.
rem... IllchmmslbC .1A,.sanm.rICIV ll cmf' an fOccmldto!y, i atureofApplicant Date
i
Owner or authoriacd agent Dam All roof coverings to be Class mB" or better
Community Development
10300 Torre Avenue
y Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: �Q PERMIT#
,
t,z) -15 po S O lao
OWNER'S NAME: PHONE # I — S�4<:7
GENERAL CONTRACTOR \-l FAX # �S C
I am not using any subcontractors:
—� --r?
Signature
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/Contracto Signatus Date
CITY OF CUPERTINO v
( G . ,., 1 N"u ti,
k� :: :..11Y�CES _.. /A
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: a mQC(�1�� P e
Es�0 �' s(oL4- I o
rr.O �I--G� Liecn�e #,�
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg 0 Elect ❑ Plumb ❑ Mech
Job Description:
Description:
AID-0 -A-l �2vvti�v �vtcQ. �z� exis�li v1 -
Residential �' , Commercial ❑
For Residential Installations:
Attic ❑ ls` floor ❑ 2°d floor❑
Adhere to min set back requirement[]
_ For Commercial Installations:
Replacement same weight ❑ Additional weight(structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: U � Type of Construction: Occupancy group:
Strapped On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty .
A 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 License BUILDING
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