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CITY OF CUPERTINOx+'
BUILDING DIVISIONPERMIT
+�CONTR�I
RACTONFORMATION�r,'.,
BUILDING ADDRESS:
041 PFNNTNCTON LN
A PERFECT CLIMATE
PERMITNO. 05120090
OWNER'S NAME:
PERMIT ISSUE DATE
ANN HUANG
10570 S DEANZA
12/15/2005
NE:
SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECTtENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Nallamfthe dunder provisions ofChapter9imylicncing
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tIS�R
Job Descri tiont3 JI ytd
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withSectionto=]000)o(Division3pf the BudnessaM ProfessiomC .Wmylicemc is
)of
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REPLACE FURNACE
uanee — Lmg
Dam CLb, ser
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ARCHITECTS DECLARATI N
I understand my plans shall W used as public meoNs
mmmm..'. �)gjygsa
Iff�1II sJ1
Licensed Pnifcuionel
OWNER -BUILDER DE Ce
.(Sero that 1 CoucaON
I hereby exempt from the Conlnclorc License law for lbe
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maso
arson. (Section ]r'3L5, Business and Professions Code: Any easy or County
1.
which
which requires to construct, alcor, improve, demolish, ore any structure
(]
its n e, also a sig
priorCement
that t of its sensed pursue t to the Novisiappo s o for suchCom Permit b rile Law Chap( statement
licensed pursuant to the of the Comment's Li cense Uw(C
Sq. Ft. Floor Area Valuation
(cormeling n] of Disuse
ono)or
r nicheegcd exempts and Proon. vi CMe)ur
exempt
cost M is Lhcmf and budisof the alleged exemption. Any
teal io u thcmfrom and or breis Any of
permit it Penalty
any applicant fora permit subjects the applicant a civil penally of
31.5 b to
-
F
Occupancy Type
not mSection than m
not more Nan five hundred dollen ($500).
0 L as owner of the property, or my employees with wages as their sole eompcnssuon,
will do the work. and the structure is not Intended or offered for sale (SCC. 7014, Business
and Prefessimu Cade: The ConoeclorS License Lew dor not apply an owner of oof
Required Inspections
Property who builds orimpmi thereon, andwho doessuchwnrk himself orthrough his
own employees, provided Nal such improvements are not intended oroRered for sale. It,
however, the building or improvement is sold within one your of compleuen, the owner.
builder will have the bumen of proving char he did not build or improve for purpose of
.It.).
❑ 1. as owner of the property, am cwhisively contracting with licensed canoectoss m
construct the: project (See Mao, Business and Professions Code:) The Contractor's U
come law does not apply is an owner of propeny.who builds or improves thereon, and
who contracts for such projects with a contractions) licensed punionno the Contractors
License law.
❑ I am exempt under Sec. , B & P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby aurum under penalty of perjury one of the following declarations;
.K and will maintain a CW Gum of Content to self -insure for Worker's Compere
cation, as provided for by Section 7]00 of the labor Code, for the pciformatxe of the
wort for which this permit is issued.
and will maintain Workers Compensation Insurance. as myuimd by Section
�vc
11Y-W-" f the Labor Code.for the perrormancc of the work forwhich chis permit is issuedrker's
ompensation Insun me carrier and Policy number sn: r
._ '� Polity Na.: C[�0
CERTIFICATE OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE
mossection need not be completed little permit is for one hundred dollars ($I00)
or less)
I amity that in the performance of the work for which this permit Is issued. I shall not
employ dn)' a son In My mNMr sn as to kronen subject to tM Workers'ComperWton
Laws of Calif Dam
Applicam
NOTICE TO APPLICANT: If. after making this Cmificffof Eacmption, you should
become subject to the Workers Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby aRrm that Nem is • connection lending agency for tbe pc,to.. of
the wash for which this permit is issued (Sec. 3097, Ci, C.)
Lender's Name
Under' Address
I certify chat I have mad this application and sum that the above inforso don is
cropi I agree to comply with all city and county ordinmces and suit laws mlaung in
building construction, and hereby autharim repmsenmives of this city in enter upon the
purposes
shove -mentioned property for inspectioneexpenses
(We) agree to save, indemnily and keep harmless the City of Cupertino against
a amts and oxpemce which may in any way eccrve against ui0 City
in consequence of the
Aconsequence of the granting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs �x
Signature of Apphcen✓Conuacmr Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building aaupanlctorc arhandle harudom material
as defined by the Cupenino Municipal Cade, Chapter 9.13, and tbe Health and Safely
Coda, Section 35573(a)±
❑rte �
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
crit havardom it emearinano as dcfncd by the Bay Area Air Quality Managcourt
District?
all new materials for inspection.
/
❑Yes
Tfn/by/
ous awrials5 tri rCcntsr6.95 r-
Ih&SgCL lCev ummamrialsmquimmentsunder Chapmrd.95oflhe Czlding
flbe builUit
nu Health&Safety Codes d25534menuun.
dues I cu n I have a Main, that it is my responotoRity m nouly the occupant of the
mem must rpml nort Ccer.omricamn(0 apaey.
.(
Signature ofAppliean Date
All roof coverings to be Class "B" or better
Ownermauthorirsdagcot Date
L
Community Development
Cu0 Torre Avenue
pertino CA 95014
IAS Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
UPEI�TINO •
Building De artment
JOB ADDRESS: II
D 3 Pen
PERMIT #
1 61-17-0 6 �Q
OWNER'SNAME:
PHONE #
GENERAL CONTRACTOR k2t&
I FAX # E61—fl-V-16
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
Owner/ Contractor Signature
Date
r1
U
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
Owner/ Contractor Signature
Date
r1
U
I
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
S-/2"L7"Y?
APN # 3/ u 3
Date:
I ree vrou
BUILDING
Building Address:
Furnace
3 e '
BREMACOVER
Owner's Name:
Phone #:
BH
REMAIRAN
A/C Units <= 10, 000 cfm
MECHANICAL
BREMRECEPT
Contractor:
?cxA-
ELECTRICAL
(k�j-e
License #:
Contact: `
�T
Cupertino Bisiness
License #:
Building Permit Info:
Mech Permit Issuance
Bldg ❑ Elect Plumb Mech
PPERMITFEE
Job Description:
PLUMBING
Residential Commercial ❑
Bld -Permit Fees
For Residential Inst ations:
13PLANCHK
Attic ElI" floor 2"d floor ❑
BUILDING
Adhere to min set back requirement ❑ .
Business License
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
C t of Project: Typ Of Constru ' n: Occupancy group:
a b y 2NAv
e if C
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. FloorArea:
New Location ❑ Replacement Q�
Qty. if
Applicable
Fee, Tr)
BENERGY
Ener y
I ree vrou
BUILDING
BREMFURN
Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BH
REMAIRAN
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
BPEKAdt,
Bld -Permit Fees
BUILDING
13PLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING