03070069 CITY OF CUPERTINO - °y r :.:s• "f '` •'
BUILDING DIVISION PERMIT 4 O0Wk CTOR�INFORMATI0N
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All,, BUILDING ADDRESS: CONDITIONED AIR PERMITN003070069
DR
\ OWNER'S NAME: 1701 LITTLE ORCHARD ST PERMIT ISSUE DATE
NE: (408) 291-2220 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION
F1 kcmby affirm mu 1 am licensed under provisions of Chapter 9 Um
omencing Job Description
with Soul Oar Division 3.(,he Bnineas ygaruc inns Code.and my Ncamcut
LamLicense As, et. / l� 7� REPLAC FU C C
9 p
DOW —At AIOL3 Cunn r
7WW k 'ARCHITECTSDE ATI N !\.
Y U 1 undcratand my plans Mall M used in politic records A
aLicensed Prof essleast
b0 G OWNER BUILDER DECLARATION
f I hereby affirm that I am exempt from the Contnnor'a License law for the
00 following reason.(Section 703 1.!1.Business and Prolamin.Code:Any city nrcount,
5$ which requires a permit to construct,alter,improve,demolish,or repair any structure 147 R
_ prior m its issuance,also mquira the applicantfor work permit to Ncasigned statementi� thatkislinnseJ purwem w Ne provisiosor the cmurmkis License law(Chafer 9 Sq. Ft.Floor Area anon
yqI $ (commencing with Section 7")of Divtsion 3 of the B usioess and Professions Code)or
(' .. Nm he is exempt therefrom and the basis for the alleged caemption.Any violation car 36611128 . 00
Section 7031.5 by any applicant for a permh subfeets the Afflicanuo a civil penalty of APN Number Occupancy Type
not mon Nan low hundred dollars(5500).
❑I,u owner or the pmpery,or my employees with wages u their role compensation,
will do One work.and the structure is not intended or offered lersde(Sec.104/,Busian, JUI
XUUU1i—
ons
and Professions Code:The Communes License Taw dao not apply k an owner or 3 0 3 - ROUGH y.
property who builds or improves fercon.and who Joe.suchwohhimalf midomigh his L
own employees.pouvidcd that such improvements an,not Intended oroffered for nit.If. 304 — ROUGH ELECTRICAL
however.the building or improvement I.sold within one year of completion.the owner.
builder will low the burden of proving that he did not build or improve for purpose of 505 - FINAL ELECTRICAL
a1e'), 507 - FINAL PLUMBING
❑1,as owner of the poultry,am exclusively contracting with licensed contractors in 508 - FINAL MECHANICAL
constwn the prefect(See.1044.Business and Professions Code:)The Contractor's Li
conn law does not apply to an owner of propeny who builds or improves demon,and.
who contracts for such projects with a contmelm(S)licensed pursuant On the Contractor's
License law.
❑I am memPt under Sec. .B k P C for ibta rrason
Owner Data
73711WORKER'S COMPENSATION DECLARATION
1 hereby afla.under pcndry,of perjury urs of the following declarations:
I have and will maintain•Cerillene or Consent to selblmum for Worker's Compton.
M
ore,ss provided for by Section 3100 of the labor Code,for the perfo charee of the
rk for which this permit is issued.
I haw and will maintain Workori Compensation Insurance,as nyuircal by Section
of the Labor Code,for the performance of the work for which this permit ta issued,
y Worker's C�om(renseuo Inwnmre prie,r/r�d licy nu ran�}� yP E S' 27oA-
�(/ CERTIFICA O COMPENSATION
N9 FROM WORKE S
COMPENSATIONINSURANCE
TIds section need nm becompleted If the lama is reronc hundred dollars($101)
or Less.)
1 certify that in the performance of the work for which this permit i.issued.I shell net
employ any person in any manners,as m become subject o the Workers'Compensation
Laws or California.Due
Applicant
NOTICE TO APPLICANT:Ir,after making Of.Coniaeak of Eacmpoon,you should
become subject to the Worker's Compensation provisions of the Ichor Code,you must
.J O forthwithamply with such provisions do this pe,.iuhalt be deemed revoked.
Z M CONSTRUCTION LENDING AGENCY
EI hereby affirm that ferei.a conswNnn lending Agency for the performance of /^\
Z) the work for which this permit b issued(Sec,309'4 Civ,C.)
4/
W Q Lender's Name.
.7 z Lender's Address
U 0 I ccnf
fy n an
I have read this application d.Tae that the.bow information information u
I74 FU cornet.I.gree to comply with all city and county ordinances and state laws relating to
O V buildingconsWction,andherebyaulhoriserepresentativesorthiscityinenterdrumde
r W above-mentioned property for inspection purposes.
6. (We)agree k saw,indemnify and keep lunnlea the City of Cuperdno against
tiy liabilities,judgments,costs and eapenua which may in any way a==against aid City
U 7 in consequence of the granting of this permit.
�7 APPIIaaICANT UNDERSTANDS AND WILL COMPLY WITH A L NOWPOINT Issued by: Date
$Ol{tIC .REGULATION �t
1147
y� ..,
gnuurc of A,limplComorcunr DataAZARDOUS TERIAIS DISCLOSURE Type of Roof _
Will donapplicam ser tn. ding acupant store or hardlc hasrdou.materia
a deaned by the Cupertino Muni el,Code,Chapter 9.17.and the Health and Safely
W
e Section 73532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant nr future b lain'accupanl d.c equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I,hazardous air emanon crowd by tht Bay Area Air Qddily Management all new materials for inspection.
nner?
❑Yes No
1 haw read thc hazardous materials requirements under Chapter 6.95 of the Caller.
Health&Safety Cate,Smims 75515,25533 and 25534.I undersand that ifft building
not currently haw a u n m.fat it is my ruporulhility m nod I the Occupant of the.
ulnmcnts 11 11 mustbemel prior lis issuance oja C,crdficem of occupancy.-10 1I �` ature of Applicant Date
cr dr amhorinJ agent ACV tate �as All roof coverings to be Class"Bo Or better
I
CITY OF CUPERTINO
4e�.
FURNACE/AC
UPEI NO PERMIT APPLICATION FORM
APN # / �(Q Date: 1 i"
_ I O�
Building Address:
5 4bW b(�
Owner's Name: Phone#:
Contractor:. Phone: License #:
(14Nb1r)t7f.1 (to % . a- ` k .12--
Contact: ^_ Phone: Cupertino Business License#:
Building Permit Info:
Bldg0El //Electr Mech 6,
Job Description: (L A-C,
Residential Commercial ❑
For Residential Insta tions:
Attic ❑ I" floor 2nd floor❑
AMLAdhere to min set back requirement El
IFFor Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: I I p o,0 Type of Construct' Occupancy group:
Strapped On Platform ❑ Bonded LJSq.Ft. Floor Area:
tr
New Location ❑ Replacement ❑
Qty. if
Applica 'e, Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfin 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 Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC I Business License BUILDING
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