05120045low
lg
0
f
�tu
C
3gs'
gEg 7K�7KC
CBS
CITY OF CUPERTINOa'>nm{,*x-
ggjG ' R`I1�IkrURM
BUILDING DIVISION PERMIT
k,0NT' ,
voJ4 rW..` ,�w"iRt4k uiH !'. tri fi
BUILDINGADDRFSS:
1057 NOVEMBER nR
AAA FURNACE & AIR CONDITI
Uii��o'05120045
OWNER'S NAME:
PERMIT ISSUE DATE
ROBERT JOHNSON
1712
NE:
SANITARY NO. CONTROL NO.
(408)293-4717
ARCHI ECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMBMECH
LICENSED CONTRACTOR'S DECLARATION
I hereby, same that I m li¢urd under pmvimans of Chapmr 9 (Commencing
Job Desc
with SaCtian01B 70of Divislon 3 oflhe Buoresssad Professions M Code,amy licence is
��
fares and
REPLACE FURNACE
License CI ! Lic.0
_
Dam usemT ".0
�FC -t
A CHIECTSnD
[understand my plata atoll W used u pubtie records
2005
��
Clewed Prefeadonal
owNER-Bu1lDER DECLARATION
1 hemlry 3171rm that 1 am amount Iran tic Convecmes License Law for the
fallowing some. (Section 703 1.5, Business and Prefcaalaa Cole: Any city or County
solemn. demolW,
3000
which requires a permit an communes, sher. or repair any structure
far r�mesLiccmle Lawd(Chapptter,9t
"Iwnmi attn�p� ajolutmeptrovisioN
Sq. Ft. Floor Area
Valera Ion
rftCCot
(commencing with Section 7000) of Division 3 of the Business and Fnfetsions Cade) or
that he is exempt therefrom and dm but, for the WIL&cd assumption. Any WolWon of
r
Occupancy Type
Sessions 70313 by any applicant for a permit wbjcm dse applicant to a civil penalty of
nm mom mon 0w budmd dolWa (5500)•
❑ 1, as owner, of the preperry, or my employee with wags as their sok compensation.
Required Inspections
P
will do the wark,and thr amt,um is Out mended ar offered for sale (Sec. A144. Bualmas
and Prefesmono Calc: The Conuacmrt I ken ee law doe, rat apply M an Owner of
q
prepnny who builds mimprowa tiuuonn, andwhadoestuchwork himselfartl mush his
own mployaes, provided dhmauch improvements m notinmadd morterd for tam. U.
'
however. the building Or Improvement is mid within ane year orcompledon. the owner -
builder will been the burden of proving that he did net build . improve for purpose of
ole.).
❑ 1. as owner of the Property, me culusiny contracting who Bttu,A cenmcturs to
Construct the project (Sec. Hued, Businau and preferments Cade:) The Camea7ars Li -
,:me Law does out apply to mown. of pmixot"Im Wilda. improv thereon, and.
who conuaN for such projects with a wnucmn(t) hemmed pursuant to the Cnnmarers
LicenY Law.
"
❑ I ran esempt under See .B l PC for this noon
Owner Dam
WORKERS COMPSNSATION DECLARATION
1 hereby affirm under penalty o(pertury mm of the following declmatianm
I haveandwlllmaimm Ce ri mor Comentmolf-immforWarkersCompen-
sdon, u provided fm by Soon 3700 of the lab. Cade. for dm pemomume of the
wart far which this permit u laud.
❑ 1 haw and will maintain Waders Compensation Insurance, u acquired by Section
7700 of the labor Code, for the performance often work f. which this permit t, Issued.
Mywarkera Co Cash imet ceani.md Policy nnuumby.mr:
��
Gorier. _J�j �C Pfa.:4L+2+f 1
C (FICA F71ONIEXEMPTION FR WORKERS'
COMPENSATION INSURANCE
(Tfiu seder word sol W cmmplemd KNe permit Is foram hunNddoOua (5100)
or less)
1 certify that in to performance of the work for which this permit is Land. I shall not
employ anyperson In any mam rso a to become subject to the Workers Compensation
Laws of Califomia. Data
Appl oyer
NOTICE TO APPLICANT: If. after making this Certificate of Esemp ins. No fiauld
become subject to the Worker's Compensation provisions or Na Lab. Cdc, you mum
forthwith comply with such provisions or this permit Nall W doomed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nm Is agency for Ne performance of
s ed (Sec. 30 7, Ch,.
' the mark for which dos perch U Issued 13..7097. Civ. Cd
'
Lsndrs None
ers Adnm«
fende
I andly that I haw teed this application and sum that the show informsdom is
n cmt.a. T agree w Comply with all city and County ardlnamu and sum laws relating to
building construction• and hsmby mad oris apmamnailm of this city to Cmserupnn tin
1 ahavomentiarmd property, for inspection purposes
(We) agree to an, Indemnify and keep harmless the City of Cupertino against
j liabllimm. judgments, caw and eapenra which may In anyway accrue against sold City
in consequence of the Simmons of this Perch.
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU"REGULATIONS.
Re-roofs
Type of Roof
Tuurt ofAppliaHAZARDOUS DISCLOSURE ��
LO
MATERIALS
WAR the applicant. forme Wilding ccupammme.handle haardaw mamrial
as deRned by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
ads. Sudan 75532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes �]No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant Or fumm Wilding occupant use equipment or dcvim which
it h.adous air contaminants a deMcd by the Bay Am. Air Quality MMISement
all new materials for inspection.
Dlsulct7
❑Yea o
I havdread Nehuards matariais requiremwunderChanmr6.95ordeCalifm-
niaHcalN&SafetyCdc Scctlam25515,25533md25334.ludmwdNmlydm Wilding
des nal cumntly Ww a se 4 Nat it k my mPonsihllily m ndl'y Inc omp.t of Ne
mqu memo which mustbe mel arm.c¢ usumof a ceruficamafOccupancy.
Signature of Applicant ` Date
zd1*
= �-- L'V
All roof coverings to be Class "B" or better
Ow r or awWriecd agent Dom'
� fi
i�
C 0,
�UPEI�TINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
/,OS -2
PERMIT_ #
L,5,S- / 2 b O `'t --r
OWNER'S NAME:
PHONE #
GENERAL CONTRACT,
fAX #
I am not using any subcontractors: A 01�
signatule ate
Please check applicable subcontractors and complete the following information
Owner/Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
�i7o
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing .
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature
Date
2-1
ITY OF
CUPEIZTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
df /z,L,� SeL�
APN # 3'6 / / (�
Z � LS �/ �—
Date:
Building Address:
BREMFURN
Furnace
MECHANICAL
Owner's Name:
Phone #:
MECHANICAL
z xv x
Contractor:
License #:
. _K,
%6 top
Contact:
Cupertino Business License #:
2
BUILDING
Building Permit Info:
Elec Permit Issuance
Bldg ❑ Elect ❑ Plumb ❑
Mech
Job De ription:
MECHANICAL
acs D
Plumbing Permit Issue
Residential Commercial ❑
BPERMFEE
For Residential Installations:
BUILDING
Attic ❑ 151 floor 2"d floor ❑
Plan Check Fee
Adhere to min set back requirement ❑
BUSLIC
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) ❑
L
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction:
Occu ancyoup:
Q� V�
LNewapped ❑ On Platform Bonded ❑
Sq.Ft. Floor Area:
Location ❑, Replacement
Qty. if
Applicable
Fee ID
Fee Description
Fee Group
BENERGY
Energy
BUILDING
BREMFURN
Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfrn
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 Lice se
BUILDING
L