04060071 CITY OF CUPERTINO �,
BUILDING DIVISION PERMIT •`41�1x'RYII�"`rC� 1� ' RM `�IdN
BUILDING ADDRESS: THERMAL CONTROL/ PERMITNO.04060071
. 20179 NW SO
OWNER'S NAME: PERMIT ISSUE DATE
SHAILENDRA SHROTRI 45845 WARM qPRTNrq BLVD JiT NE: SANITARY NO, CONTROL NO.
(510) 657-4128
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
40p LICENSED CONTRACTOR'S DECLARATION A
1 ion? affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description r /�
with SeIIion'layaffif thatI Sof Nested finess der pr Pranorf a9(Com cencair
ing !Loy
j�'1 mmnfaaaadarc 7 FURNACE REPLACEMENT .
Z License Cl Lie.p /
Lt ❑ at Coromemr -UN 'r
Q� ARCHITECTS DEC 1�, `�oo^
$ 1 untl nun my plans shall W used as pub c me Y
Dwu
;u, Licensed Professional ,II p�
QO OWNER-BUILDER DECLARATION v ���j',9�
9 I I hereby al3lrm that 1 am exempt from the Continuous License Law for the
p O following moon.(Section 7031.5,Business and Pmfeesiom Code:Any city or county
Z E m which acquires a Permit m construct,alcor.improve,demollsh,or repair any avucmm 83254
-y prior m its issuance.also requires the applicant forsuch permit to file a signed statement
sa that he is licensed punuanUothe previsions ofthe Common's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
z1- (commencing with Section 7000)of Division 3 ofthe Business and Proarsions Cuba)or
i Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of .[Q
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Y�xaritiGr 00 Occupancy e
not more than five hundred delta.(5500).
p y '.y p
❑1.as owner of the property.or my employers with wages as their sole compensation,
will do mcwok,and the atrucmm is not intended mo)rered for agile(Sec.70,14,Business
and Professions Cade:The Comment's Licuve Law darn not apply to an owner of Required Inspections
property who bas lids or Improves Nemon,and who dos auch work himself or through his
we employeas.provided Net such improvements are nalinended conRmed Torok.If,
however,the building or Improvement is sold within ane your of completion,the owner.
Wilder will have Be WrEen of proving that he did not build in Improve for purpose of
WO.
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70,14,Business and Prefearions Code:)The Contractor's Li-
me law dos not appy in an owner of property who Wilds or improves Neuron,and
who concocts for such projects with a conmemna)licensed pursuant to the Commetor'a
License law.
❑lamexemptunder Sec. ,B&PCforthismsson
13700of
r Data
WORKER'S COMPENSATION DECLARATION
I hereby dTmm under penally of papery one of me fallowing declarations:
have and will maintain a CartiMBe of Consent.sair-mi um far Workcri Camper.
.as provided for by Sudan 3700 of the Labor Code,for the performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
the labor Code.for the performance of the work for which this permit is issued.
orker' am not marane carrierand Polnymon a
iu. Policy No.:
CERTIFb..A ^OFEXEMPIONFRO RKERS'
COMPENSATION INSU CE
Mix section need not W completed lithe permit Is formic hundred dollars($100)
or less.)
I certify that in the performance of Inc work far which this permit is issued,l shall nm
employ any person in any manner so in to become subject o IW Workcr£Compensation
Laws of California.Gets,
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
became Subject to the Worker's Compensation provisions of the Labor Code,you must
.J 0 forthwith comply with such previsions at this permit shall W decreed revoked.
z CONSTRUCTION LENDING AGENCY
14[+ I hereby affirm that there is a coolroction leading agency for the performance of
a> me work for which this permit is issued(Sec.3097,Co,C.)
Q Undoes Name
0z Lenders Address
U Q 1 minty Nat 1 have need this application and seats Nat the about infornoodun is
{e. coma I agree in comply with all city and county oudmaces and state laws relating to
U construction, auls
building construction,Sod hereby odm ministrations of Niter s city to enupon me
ahova-(We)agree
ba s re for inspection
mnify an keep ha. /t ^
G ju agrees,ave,indemnify and keep hay I.an the City of Cupertino against
t�
liabilitiestiencof eCodaandexpeaRa which may la any way BceNC against old City 6/
C)z rAnPPLsIeCgAcncc of ERSTANDf mnNO SILL COMPLY WITH ALL NO ,PryOIN _Issued by: Date
SOURC LATIODTS, (J
b Re-roofs
6 ofA pi n
OUS MATERIALS DISCLOSURE Type of Roof
Sri
.innilamlor four.buil in6 ucupanumrc ar handle Woo u nnimn.1
as defined by me Cupertino Munici 1 Code,Chapter 9.12,and the Health and Safety
Sv seatioa zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea o
Will me eppliaanl or future Wi ng aecupant asst equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Me Pilot hasvtlnus air cameraman.as Food by the Bay Ama Air Quality Management all new materials for inspection.
District? /
❑Yes �T
1 have read the heasohms materials requirements under Chaper6.95 of the Califar
ria Haahh&WayCode,Sectiom 25505,25533 aml]5534.1 understand thetirthe building
dos not currently ham 4 that it is m maporni "y m rmdly me scup t of
rcyuiremcnts ien etpnoTwi en or rdgcaeoracupaBe Signature of Applicant Date
(/Dl 0
ow g mlbate All roof coverings to be Class "B"or better
Community Development
y� 10300 Torre Avenue
1 Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRE 7 nvr �� rs/ ie� �a-Q're RMIT#
Gl /v/a J,u�/ Xb 07�
OWNER'S NAIy¢r ar >ba y-o PHO
GENERAL CONTRACTOR: / FAX
I am not using any subcontractor . rzl " rp p
at
Please check applicable subcontra or cC— a-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' -
d �
a
-� CITY OF CUPERTINO (� o o
FURNACE/AC
8UPEkTING PERMIT APPLICATION FORM
APN # Date:
Building Address n ) (A 50W'D/�{:
Owner's Name: L� /"�
r 5 P�Drf C � I
Contractor: f hone: kens #: /
Contact: Phone: 3 Cupertino Business License#:
Building Permi Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech L�
Job Description:
Residential Commercial ❑
For Residential Inst ations:
ttic ❑ 1g` floor 2"d floor❑
adhere to min set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑ j
New installation Planning Approval Required El
Cost rojec Z Type of Constructi Occupancy group:
Strapp ❑ On Pla form ❑ on ed ElSq.Ft. Floor Area:
New Location ElR lacerttent
Qty. if
A cable 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 cf n 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
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