03110032 CITY OF CUPERTINO
BUILDING DIVISION PERMITCOufT'4 RAC' T..LO3 RNinF• ,0."R: ...I, iN
lfa.e'fYi/!k
BUILDING ADDRESS: - PERMIT N00 3 11 0 0 3 2
ORC PARK VTT.T.A M.
OWNER'S NAME: PERMIT ISSUE DATE
AULA & NOLA I UIN ERNO 11/06/2003
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� 0
+Oo LICENSED CONTRACTOR'S DECLARATION
�uF 1 hereby affirm that I am li.nsed under provisions of Chapter 9(commencing Job Description
¢W with Section 7")of Division Sof Ne Business and ProfcaMuns Code,and my license is
<o°' Lifull force s And
Lk.N ermeL
Licenx ClREPLACE FURNACE & ADD A/C
;;,o Dale Camracmr CONTRACTOR: FREE AIR (${24931)
ARCHITECT'S DECLARATION
IU I understand my plans shall he used u public records y
6 }/
guy Licensed Professional
cog OWNER-BUILDER DECLARATION ��/
�el 0 1 hereby.(firm that 1 em exempt from the Contractor's License Law for the
p o whicfolloh Am..on.Permit
]PULS. t,alter. and Pm(cuinns Cute:Any city ns county O
which¢quires a permit Ie construct,pima improve,h permit t or e4 sir anygned statement Ely that he iuisuancc,aluantto me the
ovisiosOf mesuch permittoLBlcasigawJaanmcm
rimes (commencing
com encinnWJPsectio 70M)ofvivionsnfththe8uscmrinironalaw(Chapter 9ode)or Sq. Fl. Floor Area Vanua[ 000
dl- Ourhe ,monnn section And
DivisionJnr theeged euand Professions Code)or
$ Nm Section
u exempt thcmfrom and Ne baso far the alleged exemption.Any violin lty of
not.n]On by vemyapplicantfarapermitsubjectsNeappliunuo-civilpenaltyof 39&Ilal0,Q*iSer00 Occupancy Type
not mon Than five hundred dollars(55007. P Y YP
❑ 1,As owner of the property,or my employees with wages u their sole compensation,
will do the work and the structure is not intended or offered for sale(Sm.7W,Busineas
and ProLicense Law data not apply to an Professions Code:The Contractor's Liceowner of Required Inspections
property,who builds or improves thereon,and who does such work himself or through his
Own employees,provided that such improvements Are not Intended mattered for ole.IL
however,the building or improvement is sold within ane year of eampledion,no owner.
builder will have the burden of proving Nal he did not Wild or improve for puryme of
sale.),"
1.o owner of the properly,am exclusively conmming with licensed contraelon to
c that'Ne projen(Sec.7044,Business and Professiem Code:)The C.meacters U
came law dma nor apply to an owner of progeny who builds or improves themon.And
who contracts for such projects with a eontractar(s)licensed pursuant o the Contractor.
Liccnm law.
\
LOA:
1 am exam t under Sec. �— B k P C for this moon
per �A z r�...:./YA Date//
WO ER' A ION DECLARATION
1 hereby Mrum under Penalty of perjury one of the following declarations:
7c,
ave and will maintain a Certificate of Consent to Self-ImYrt for Worker'sGOmPCm
,a provided for by Section 3]00 of dm labor Code,for Ne Peaformarcc of the
for which this permit is issued.
ave and will maintain Workers Compensation Insurance,m required by Section
of the labor Gude,for drt performance of the work for which this permit is issued.
orkers Compensation Insurance carrier and Policy number art:
r.
Pulley No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Iiia action need not hecomplemd if the permit Is Boom hundred dollars($100)
or less.)
I certify not in the Performance of the work for which this Permit is issued,I shall nm
employ any person in any manner so As to hecome subject m the Wcolums Compemalio r
Laws of Califomie.Dale
Applicant
NOTICE TO APPLICANT:if,after making this Ceniacate of Exemption,you should
become subject to the Worker's Compensation provisions of Ne labor Code.you must
., z forOwi th comply with such provisions or this Permit shell de deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there its construction lending agency for the performance of
> Ne work for which this permit is issued(Sec.309],Civ.C.)
Ig1 0 Larhu,'s Name
= z Lender's Addrom
U Q 1 certify that 1 have read this application and sum that the above information is
U. F correct.I agree to comply with all city and county oNinances and sum laws relating to
C) U building construction,and hereby authorise representatives of this city to enter upon the
W shove-nomioncd Prapcny Am impeetirm Purposes.
gy (We)agree to an.indemnify and keep harmless the City of Coporthm against
fA liabilities,judgments,costs and exKnsm which may in any way accrue against aid Ci ly
UZ in consequence of the grand ag of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU�CEREGULATIOyS ��
`/�.g0. G'=' a/ //�6�03 Re-roofs
Signature ofXp'pTicinargbaclor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant stare or handle havardous material
u defined by the Cupenine Municipal Code.Chapter 9.12,and the Health and Safely
oJc,Sc❑e'Yoean 25532(x)? �a(\1JNO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i'hazardous air contaminants m defined by the Bay Area Air Quality Management cep new materials for inspection.
is ict]
❑Yes IATJu
1 have maul Ne haaMeus materials requirements under Chapter 6.95 of the Callon
nia Hcallh&SMCly Cn ,Sccduns 25505,25533 ad 2553a.l undcntand Rut iHhc huilding
docs not cmnrcody have a tenam,Nat it is my responsibility to notify the Iccuput of thc
rcqui ms which mustbcgtmet poor to-issuance of a Cereficale or Occupancy. Signature of Applicant Date
owmm�raamori..Ja`�ant Q,k All roof coverings to be Class "II"or better
CITY OF CUPERTINO D a r r a3 Z
FURNACE/AC
@LUPEfZTINO PERMIT APPLICATION FORM
APN# Date:
Address: S 0 8(� `Par k \j1 ��a Cre Cu 2ef Ti n o CA
Owner's Name: PPhone#:
ain Note , + ��� 409) ass-iso I
Contractor: Phone: License#:
vl
Contact: Phone: Cupertino Business License#:
1
Building Permit'Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
ntialIn llations:
Attic ` floor U 2nd floor El
d o min set back requirement❑.,
IW'For Commercial Installations:
Replacement same weight ❑ Additionalweight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning ApprQval Required ❑
Cos o' t: — Type of Construction:, Occupancy
Strapped On Platform ❑ Bonded ❑ Sq.Ft. Floor Ar .
New Location ❑ Replacement ❑
QtY•
App,Kc4blkFee 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 cfm 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 Bld.2 Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC I Business License BUILDING
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