04060085 CITY OF CUPERTINO "�'M y � � +w
BUILDING DIVISION PERMIT ' CONTRACTOR INIi'C?R� TION.
BUILDING ADDRESS: RESIDENTIAL HEATING AND A/I fERfRNC04060085
10194 PARISH P
OWNER'S NAME: PERMIT159UEDATE
dhi CHU CHUTAN HSIEH 65 CRISTICH LN 06/09/2004
ONE: SANITARY NO. CONTROL NO,
4083774073
ARCHITECT/ENGINEER: ,4 BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
YO Op LICENSED CONTRACTOR'S DECLARATION
< �,{ 1 here Tito Nn 1:m licensed under provisions of Chaplet 9(commencing Job Description
'n E with Sccuonl of DUOmon3afdm BuSmsxxandP tssimu Codc,andmyliccnxis
E inmBm¢ a effee. v FURNACE REPLACEMENT & ADD � �(L�
5 SDECLA
�z License Cl 7. Lic.N — - f{
nay4- Dam es OY Contractor -
ARCHI
lKPIPION
M< 1 understand my pl ns Shalllhhe uussed as public records
JUL 6 2004
�yU
Licensed Professional
5 OWNER-BUILDER DECLARATION
E:0 f 1 hereby affirm on 1 am exempt from dprofessions
Comment's License Law for the
00 (allowing moron.Parrott
r 703 1.3,Business and ve,de i demolish,
Cedc:Any city urcounty
ante BUILDING
K$ which requires a permit re cores the alto[improv$,demolish,m mash any swctum 84490
FZNy primto its iensedpelnntin the lhovisiappos or for such permit to file a cense signed )mem
xx
that hcencin with
7000)
)ofiiona 3ofthe tha usinesandPnselsw(C Coda)
Sq.Ft.Floor Area Valuation
'at he is exam iN Secli)n 70nd the
bsDivision r the al Business end Professions Cnde)or
Net he u exempt Nemfrom and Ne buss for the alleged exemption.Any violation of
Section 7031.5 by Ory applicant for a permit Subjects the applicant to a civil penally of
net mom than five hundred dollars(S500). Occupancy Type
❑I,as owner ofthe property,or my emplaycas with wages as their sole compensation,
will do the work and the structure B notintended oraRered forsale(Sec.7094,Business
and Professions Code:The Contractor's License Law does net apply to an owner of - Required Inspections
property who bol I ds o,improves thereon,end who dew a tach work himsel r or through his
own employees,provided that such improvements are not intended orofiered forsale.IL
however,the building or improvement Is sold within one year of completion.the owner.
Wild.,will have the bu den of proving that he did not build or improve for purpose or
ml).).
❑1,as owner of the property,am exclusively contracting with licensed rontnmmrs to
construct the project(Sec.70",Business and Professions Code:)The Contractor's LI-
came Law does not apply to an owner of property who builds or improves themon,and,
who contracts for such projects with a conuacmKtl licensed pursuant to the Contractor's
License law. ,
❑1 am exempt under Sm. .B&P C rm this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby cutin under penalty of perjury one of Ne following declarations:
1 haw and will maintain a Cwifctue of Consent tosetf-Umrt for WarkerSCompen-
-lion,as provided for by Section 37011 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
1700 of NC labor Cede,for to performanm of the work for which this permit is tamed.
y ric(er's�Compensation Insurance carrier and Policy number am:
425�r/N(] Policy , c
CERTIFICATE OF EXEMPTION FROM WORKERS'O
COMPENSATION INSURANCE
(This section need nthecomplemd if the permit is Intent hundred dollum(SI00)
or less.)
1 certify that in to performance of the work for which this Permit is issued,I shall not
employ any person in any marm rse ss to become Subject o the Workers'Compensation .
Laws of Calif Trio Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become$Object In the Worker's Campcnsnian provisions ar the labor Code,you must
.70 foMwith comply with such provisions at this permit shall he deemed mvokcd.
nzt I CONSTRUCTION LENDING AGENCY
[ti l for which thi than Nem its emwSec.30 lending agency for 0th performance of
ai ti the work far which this permit Is issued(Sec.J097,Civ.Cd
W�Q Lender's Nam
r7 z Lender's Address
iJ Q 1 certify Net 1 haw read this application and sum that the above information is
{L.(~ corecL 1 agree to comply with ell city and county on inncee and sum laws misting to
Q V building convection,and hereby auNorin mprOsenutiwa or this city to enter upon the
LQ.T7 ahow-m)ntioned property Tor inspection purposes. ( \/�tQ�//��//
z (We)egme h sew,indemnify and keep humieu the City of Cupertino against Y DC."' l
f.y y liabilities,judgments,costs and expenses which may in any way name against mid City
V'� A consequNT of the gremting this permit.
., APPL NT UNDERS SAND WILL COMPLY WITN ALL NON-POINT Issued b
50 C RE N .
Re-roofs
tort of Applica Convenor, `Dam
AZARDOUS ERI LS DISCLOSURE Type of Roof
veil the a Ppm.m.rfmurgvbuYl gottupmutore.,handle herardous memo.]
US defined by We Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Co dc,S)ction 25532(¢)?
❑r)$ Na All roofs shall be inspected prior to any roofing material being installed.
Will,the applies.or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
vill mit hazardous air comminnts as dcfincd by the Bay Arca Air Quality Management all new materials for inspection.
Dlxtricl?
❑Yes No
I have mad the hemMmua rusamialmcquimments under Chapur 6.95 of the COW-
Us Health&Safety Conn.Seen.25505,25533 and 25534.1 understand that ifthe building
docs not curtenit have a tenant.th 't b my responsibility to notify the oc upnt of the
mquimmcnu hoe sem rtou$ane)nn 'ficateofOer. Signature of Applicant Date
cea
,,O
Oatc All roof coverings to be Class "B"or better
tar uNoriaod agent
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
Building De artment
JOB AD]�RESS: PERMIT#
!� '0 4`f
OWNER'S NAME:"C' C�fU c �N Got PHONE # 7S7 7- tto7 3
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check a h ble subcontractors and complete the followin information:
SUBCONTRACTOR ' BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
�A Glass / Glazing .
Heating r, e 2 1c1
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ontracto Signature date
a
CITY OF CUPERTINO
FURNACE/AC
SUPEkTINO PERMIT APPLICATION FORM
AP
N # alb (� V 3J
Building Address:
O t 4
Owner's Name: Phone #:
0519-4
CAntractor- Phone: License#:
�Lj M41 fYRnJ r Y0,g - S � ?. (-fo7 -7 c) S5S`f
Contact: Phone: Cupertino Business License #:
s Lfo 7
Building Permit Into:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
C
Residential [ Commercial ❑
For Residential Installations:
ttic ❑ ls` floor ❑ 2"d floor❑
Where to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installatio i A roval Required 0
Cost of Proje O ype of Cons Occupanc cup: /9 r
Strapped ❑ On Pl t orm ❑ BondedE1 Sq.Ft. Flo ea:
New Location ❑ Replacement
Qty. if
A 11 a le Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BRENUVRN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 c$n MECHANICAL
BRE�HAN 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 Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING