05020180u
CITY OF CUPERTINO
LJNFORMATION
BUILDING DIVISION PERMITCON>TRACTO
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BUILDING ADDRESS: _
CONDITIONED AIR
P�IMITN'05020180
OWNER'S NAME:
PERMIT ISSUE DATE
SRINIVASA
ZONE:
SANITARY NO, CONTROL NO.
(408)291-2220
ARCHITECTIENGTNEER:
BUILDING PERMIT INFO
BLDjL— E�� PLUM= MECH�
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06
LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby anion that I am licensed under provialma of Chapter 9 (commencing
with SoclianT111O.f Division Sof the Buaims,md Profession, Code, and my license is
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on
infanmmeanaer t. ` L I °J
IJeeme C s Lie. g
FURNACE IN ATTIC & ADD A/C
ser 2
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Dam COnlaate, (lf)1�rj
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ARCHITECTS DECLARATION
1 undcrmen'myans Nal used wpubl Tic records
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OWNER -BUILDER DECLARATION
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I Wreby aRrm that 1 am eacnpt form the Contractors Lt... Law for the
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following mason. (Section 7031.5. Business and Prefevions Code: Any city or county
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which requires permit to enm m. alter, improve, demolish, m repair any structure
prior to its issuance.also requires the applicant for such permit m file a signed aulemcul
that he is licensed to the of the Connumr'sUmme Law (Chapter 9
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Sq. Ft. Floor Area Valuation
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pursuant provisions
(commencing With Section 70)0) of Division 3 of NO Business and Professions Cue)or
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trust ha is exempt therefrom and the bssu for the alleged exemption Any violation of
Section 7031.5 by any applicator far a permit subjects the applicant o a civil Penally of
3 6�NtffiEbe10 0
Type
not nam than five hundred dollars ($500).Occupancy
Q 1, u ownu of Na prepmy. a my employess with wgu u Ne'tr role rompensatim,
will do thework. end the sweture is ml intended or offered portals (Sec. 7044, Business
and Profwiom Code: The Contractor's License law does Ilan appy to an owner of
Required Inspections
property who builds or improv thereon, and who does such work himself or through his
own employees, provided Our such improvements sae not intended moRered for sale. If.
however, the building or improvement is sold within one year Of completion. the owner,
builder will have the burden of proving Nal M did not build or improve for purpose Of
.It I.
O 1. as Owner of Ne property, am exclusively contracting with licensed mnuxrors to
comrrml IM pmjeu (Sec. 7044, Business and Professions Code:) The Commcnri Li-
oense law dors not apply to an Owner of property who builds or improm theme. Md.
who contracts for such projects with a eormseror(s) licensed pursuant to dm Contractors
License IaW.
❑ larn.m.nundu Sec ,Bk PCRu Nismsson
Ownu� Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pedury on, of ted following decimations:
I have and will maintain aCertiOnm of Consent to self -insure for Workers Compere
sation, as provided for by Section 3700 of the labor Code, for the performance of the
work for which this permit is issued.
have and will maintain Wmkers CompensauM Instar . as toquired by Section
700 of the labor Code, for dm performance of the worts for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
np
Grier. �rf 3iicTlr's\ �\OS(PolicyNm.: �'I II'ICig_
I CERTIFICATE OFEXEMPION FROM WORKERS'
COMPENSATION INSURANCE
Rhin scrim need not Mcomplcwd if the Permit is forobe hundred dollars ($100)
m Its..)
I unify that in the perfnomamc of Ne work for which this permit u issued. I shall not
employ any person in any manner an as re Wcomc subject o the Workeri Compensation
Laws of California. Date
,
Applicator
NOTICE TO APPLICANT: If. after making this Certificate Of Exemption, you should
become subject to the Worked Compenselion previsions of the lahm Code, you must
Oforthwith
comply with such Provisions or this Permit Nall W doemcd revoked.
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
ted woh for which thus permit u issued (Sec. 3047, civ. C.7
Lcndw's Name
Lender ddrcas--
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1 cervi r1 have reed Nis application and sum that the ahem infometiun is
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Fcones
1 egme w c ly with all city and county ordinances and state laws relating to
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Wildingmmsoumian,an rehyauthorim mpmsenutims, of this city m enter upon Nc
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Mem o muoned property (m coon purpoxs
(We) agree to save, indemm keep harmless the City Of Cupcnina against
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Ij.bilidcajudSnmms,mam.Mtxp-1bey in any way accrue against said City
in comegmnce of the granting of Nis permit.
APPLICANT
._
UNDERSTANDS AND WILL COMP L TH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
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A-4440urcRe-roofs
Appr[MM tr tsDate
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Ne applicant m future building mcupant More or handle haounkno mamrial
ss dcRoed by Ih Cupertino Municipal Code. ChaPmr 9.12, and the Health and Safely
oJc. Sce on 25532(a)?
El Yea _.'�INm
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant at future building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
crit hazardous air contaminants u defred by IW Bay Arta Air Quality Management
DiWict?
all new materials for inspection.
❑Yes K;Nu
I have read the hvardnusmsterials requirtments underChaper6.95 of doe Cslifor
our Hesfthd: SafcyCodc, Sectors 25X15.25533 and 255X.1 understand thxtifthe Wilding
dom not currently ham. W ML that it IS my maPonslbiliry or notify the =UPNI Of the
re I out which most be (palm I Of a cmurhate orQNpaney.
Signature of Applicant
PJ/,C(i ti -� r'Mc. /n S
Date
Ownm.drauthmi ed.9mt �..i rare
All roof covermRs to be Class "S" nr tenor
C,TT, 0,
�UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
O r ,r.
PERMIT # -
C50 90 l $O
OWNER'S NAME:c�) � uazsa V,�t
PHONE # C4oS) O4 -9�*.5
GENERAL CONTRACTOR: }
FAX # C40g gq i • 9-b* y
I am not using any subcontractors: -
Signature Date
Please check applicable subcontractors and complete the following informatiom
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Owner/ Co6ntractor Sign turre Date
66
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
i _I rc& � ajL/aS
Owner/ Co6ntractor Sign turre Date
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•
CITY OF CUPERTINO
-19 FURNACE/AC
OF
CUPEkTINO PERMIT APPLICATION FORM
APN # 366 1 to S
Date:
Building Address:
BREMFURN
7 5 e bI o &rn -pR•
BUILDING
MECHANICAL
Owner's Name:
Phone #:
Sr. Ivosa -Dee
O9 - a qQ • q -7a
Contractor: Phon :
License #:
ac, , - qt -
445I Io ;k.—
C ntact: Phone:
�St" laf, U,,u
Cupertino Business License #:
-aql - aa&
as a
Building Pe it Info:
Seismic Commercial
Bld cpl— Elect Plumb El--'
Mech Ur--�
Job Description:
ELECTRICAL
k MPERMITFEE
Mech Permit Issuance
Residential „� Comfnercial ❑
k' PPERMITFEE
For Residential Installations:
PLUMBING
Attic 09—lS` floor ❑ 2"a floor ❑
Bld Permit Fees
Adhere to min set back re uiremeraD ,
BPLANCHK
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural talcs) ❑
Business License
Structural Calculations required for new installation ❑
New installation Planning A roval Required ❑
Cost of Project: Type of Construction:
Occupancy group:
Strapped ❑ On Platform 13Bonded LlSq.Ft.
Floor Area:
New Location � Replacement ❑
Qty. if
ADolicable
FPP rr)
BENERGY
1� 1101 11 11V/1
Ener
r ee urou
BREMFURN
Relocation of Furnace
BUILDING
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
BRENMCEPT
Rec ti, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILIDNG
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
k MPERMITFEE
Mech Permit Issuance
MECHANICAL
k' PPERMITFEE
Plumbin Permit Issue
PLUMBING
BPERMFEE
Bld Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING