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04010086CITY OF CUPERTINO Q�z �uaaa BUILDING DIVISION 1 E PERMIT x` R CONTRACT-=O�INFORMATIQN° ' ❑ UILDINGADURESS: 'A & HHEATING PERMIT ND. 04010086 OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARYNO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERM R INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED OWMAC OIVS DECLARATION 1 cr affirm the, I am licensed under provisions of Chapter 9 (commencing Job Description p With Section 70110) of Division J Of me DeanesxandP positions Code. and my license is in fullfnrte snit ffcc 7ji Lic. N v,�a g,{ REPLACE FURNACE -ADD -A/C PINALEO Do.u Dak �' Cunuackr ARCH] CPSAECLfRAI Iundcrs,ano myplainabaftbeusedupubl'c no - FEB 2 0 2004 Licensed Profcssiunsl Oat NEm DECLARATION DECLARATION I hereby affirm thin 1 em exempt from the exempt t License law fur the ' BUILDING following reuon. (Section 7101.5, Business and Professions Code: Any city ar county which requires a Permit In construct. Riser, improve, demolish, or repair any structure prior hr its iuuoncc, also sequins the applicant for such permit to file. signed nemmcn, that he is licensed pursuant to the prolix efor of the Coin.1to's License Law (Chapter 9 Sq. Ft. Floor Area - Valuation (commencing with Section ]IXIO) of Division J of the Business and Professions Cock] or Net he is exempt therefrom and the basis for Ne alleged exemption. Any violation of Section ?031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3%.A ftn*qr00 Occupancy Type not more than eve hundred dollars ($50B. ❑ I, u owner of the property, or my employees with wages m their sole compensation, will do the work and Ne atrunert is not intended minGened pomata (Sec. ]001, Business and Pmfcesiom Cede: The Conuaclor'a Liaise Taw aces an, apply to an owner or Required Inspections property who builds or tmprom thereon, and who does such work himself ordimugh his own employees, provided that such improvements are not intended or offered formic. If. however. Ne building or improvement is sold within one year of comphoom. Ne owner. builder will have the burden of proving Nat he did not Wild or improve for purpose of ask.). ❑ 1, as owner of Ne property, am exclusively contracting with licensed contractors to construct the project (Sew 7W, Business and Profesions Code:) The Contrumr's Li. cense law does not apply to an owner of property who builds or improves domain, antl who contracts for such projects with a contnnmDl licensed pursunl10 Me Contramor's _ License law. ❑ I am exempt under Sec. . B & P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury um of the following dalantimor I have and will maintain a Cenifcate of Consent to ulf-insu a for Worker's Compcm I u provided for by Section 7]00 of the labor Curie, for Ne Performance of the . rk for which this permit is issued. 1 hove and will maintain Worker's Compensation Insurance, as required by Section. 10f Ne Labef Cede, for Ne petfmmantt of Ne work for which Nu permit is Issued. Workers Comp/aaansl�al/iilnsunntt estncr and Paliryn rt:rrlef: �tlilC �AiS Polley No..Wo 7 ' CERT FICCERT FI ATE OFoPfION WORKRS' , COMPENSATION INSURANCE (Thu section need notlecomplead if the Permit is preen hundred dollars ($100) or less.) 1 certify that in the performance of the work for which ,his Permit B issued. 1 shell not employ any person in my manner an u to become subject o ilk Workeri Cempenmtion 4ws of California. DateApplicant NOTICE TO APPLICANT: If, after making this CCP1RCaLO of Exemption, you should become subject to the Worker's Compensation previsions of the Lehr Code, you moss fonhwi,h comply with such provisions Or this Permit shall be dccmed revoked. CONSTRUCTION LENDING AGENCY 1 hemhy affirm that there its construction lending agency for the Performance of Me work for which this permit is issued (Sec. 5197, Co. C.) tanacr'a Name ,. lender's Adtlmu 1 cattily Nn 1 have read this application and sum Nat the above information is ' coned. 1 agree to comply with all city and county ordinances and sok laws sedating to Wilding connection, and hereby authodm rtpresen W iwe Of this city to enter upon Ne above-mentioned property for inspection purPOOm (We).,nm to sove, indemnify and keep hMIkE the City of Cupertino against liabilities, judgments. costs and expenses which may In any way cc= against mid City in consequence of the Panting Of this Fount. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCEEGULATIONS. Re -roofs . Type of Roof nature o ApplianUCommcmr y Data HAZARDOUS MATERIALS DISCLOSURE Will Ne applicant or future building Occupant atom or handle hazardous material u dented by the Cupenlno Municipal Code, Chapter 9.13. and the Health and Safety Cmle. section 35532(U] PIC C]Yes roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Wil; the applicant or future building aaeupant use equipment or devices which It hazardous air comeminants u defined by the Bay Area Air Quality Management all new materials for Inspection. nricO [3 YO, I have renes Ne hicaNtws materials requimmenu under Chapter 6.95 of the Califon nia Health& Safety Cade, Section 35515,25533 and 35530. l undenrarA that if the Wilding does not cu o M1aw a moan that it is my ouponsibility to nouly Ne necupro, of the _ rcyulumc ticnmust them etprin mcee cemneaknr npancy,Na ignatureofApplicant Date All roof coverings to be Class "B" or better r et anmwdma.gcm Date CITY OF CUPERTINO CITY OF CUPERTINO FURNACE/AC 8 PERMIT APPLICATION FORM 0 �0100�a APN # 3 � q 16 0 8 Date: — Zen- BUILIDNG Building Address - 10 PAM (SL - - -- Relocation of Furnace Owner's Name: C Phone #: 39 8 - 8_.3_- Contractor -License � � f f < License #:� �� — A/C Unit > 10,000 cfm Contact: r � bA A+6LPS Phone #: c2 71 -02 A/C Units <= 10, 000 cfm Applicant/Contractor: `rlUlo � G Rec il, Switch & Outlets Building Permit Info: Blda Elect Plumb Mech _ JobDescription: C, Residential: 1140G ornmcreial: Scl.Ft. Floor Area: / / S/Scl,.Ft.: Ll BUILIDNG ArchitecUEngineer: Valuation r� Type of Construction: EPERMITFEE Occupancy Gro tf11 n11,rIl a FPP Tn Fee Description Fee Group BENERGY Energy BUILIDNG BREMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit > 10,000 cfm _ME CH_ATV IC.AL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BREMRECEPT Rec il, Switch & Outlets ELECTRICAL BSEISMICRE Scismic Fee Res BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG