04110041J
F1CITY
OF CUPERTINO "`
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.. BUILDING DIVISION ,.� :PERMI'T; •.
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BUILDING ADDRESS:
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PERMIT NO. -
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A PERFECT CLIMATE
04110041
"lt3r1AMKUSAXiU
PERMIT L4UE DATE
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sANITARY11101 08 2OthkROL NO... .
ARCHIIRCOENGINEER:'
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BUILDING PERMIT INFO.. .
BLDGELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION.
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Job Description
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Brl l ata undJqtr previsions of Chapter 9 (Commencing
horeb m vea R
with Sec n )of0ivi ov]oflMBusitess7adTtofagalun Codamelaylicenmis
in full fO d effect. �/ /1' // VV 15
License are ////�� Lle.g
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Delc Comramer '
�\ unAR HRECrs ION
' ��Wifdersd sect shall he used ie mcmds
REPLACE FURNCAE & ADD A/C. -,..�
Cline
Licensed Professional
- OWNER -BUILDER DECLARAnON
I herohy I -from the Committee License Law for the
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alarm that am exempt
following .... (Section 7871.5, Businega and Profeminn Code: Any city or county
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which requires a permit 10 cn t. Wm improve, demolish. an repair any .=[am
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prior m its iuumce. 1130 wariims the applicant for such permit to file a signed statement
be is limned to de -of the Commetori LiWttm Law (Chaper9
Sq. Ft. Floor Area
Valua t1h190
That Instant provisions
..
(Wmmmeing with SuOmn 7000) of Division 3 of the Business and Proresslon Code) or
he u Bmp them rom and Oe besii ror the alleged exemption. Any WalAtion of
that u
� ppN Nt�tlber
Occupancy Type .
Section 7031.5 by any applicant for a permit objects the applicant in a civil penalty of
oat mom thin five huadtW doll. ($5Dm.
3 5 619 O.i y .00
❑ I, as owner of the property, or my employes with wages as 11eG sole ownwarallon,
'
Required Inspections
will do the wak ad theauuctues a nal handed or offered for sale(Sec. Trial, Business
and Profession Cade The Commutes License Law don nm apply m an Owner of
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property who hWldt m improver thenson. and who does two must himself or through his
awn employes, provided that such improvements arcus intended ne offered far same. if.
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however• the building or improvement it mid within ane Year of Wmpletim, the morm.
Wilda will have tie burden of proving that be did not Wild or improve for pro= of
sae.).
❑ 1, ss Owner of the properly am exclusively connecting with treatment Wanmlon to
connotes on, project (Sec. 7044, Business and llornsioru Code:) Tbe Co memes L4
Cartoon Law data not apply to an owner of property who Wilds or improve thereon. and
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whocontrace, for such projects with a mnumor(s) licensed pursout in the Consumer
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License Law.
❑ I inn eumpt under See ,B At PC for this mssm
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Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby &Rml under penalty of perjury am Olins following declustions:
I haw and will mainain a Certificateof Consul to self -inure torwortmesCampen-
tion as provided for by Stttinn 3700 of the tabes Code, for the performance of the
'
wine which this pertna is issued.
r, as required by Section
1 have and will maintain Workees Competion Itnmanu
Compensation
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3700 of the Labor Code, fort thhepepRn/alarmance a(tW wore for which the permit I, iismuL
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CERTIFICATE OF 0 MPIO OM WORKERS'
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COMPENSATION INSURANCE
(Thu section nand trot becmnpkted if the permit is far. hundred &it. ($100)
or iris.)
I certify that in tie, performance of the .,it fn which this permit is issued. I shill not
employ any person in my mum, m ar in become subject to the WneeR Computation
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laws of California. Data
Applicant
NOTICE TO APPLICANT: If. net making Nu Ocdifiam of Exemption. you should
ba0me subjM to the Wo lm s Cose,c1Wtion provisions of IW Labor Code, you most
forthwith amply with such provision re this permit Nall be decreed remked.
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CONSTRUCTION LENDING AGENCY
I bemby ofrrm that Neu is a Con ectton lending agency for the performance of
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the work for which this permit u stand (Sec. 3097. Civ. C.)
Landers Name
LaniehAdd.
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1 eerily that i raw mad this application and sate Nal des above information is
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coma T agree to Comply with all city and county minnows and sea laws mining in
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Wilding convection. and hereby unwise mpreunutives of this city reenter upon the
abew-mentioned Impeny for inspection purposes
(We) agree to gave, indemnify and keep harmless the City Of Cupertino against
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liabilities judgments, cons and expenses which may in my my amuc gmma saidCity
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in Wanardsoce of IW gooling of this permit.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON.POI
Issued by: Datyejn� '
souac LAn s.
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Re -roofs
OfA plias mtmemr Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Wel the applicant or forum building occupant tom or handle haaamon material
as de0ncd by tie Captain Municipal Code. Chapter 9.11 and ON Health and Safely
Cade. Section 255320)7
DYn a
All roofs shall be inspected prior to any roofing material being installed.
-' inspection,
If a roof is installed without first obtaining an I agree to remove
Will site Applicant or m Wilding occupant use equipment ortkvi=which
mit hanmous air Wntseninants ss wrined by the Bay Am Air QuaiiLY Management
all new materials for inspection.
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Myodc,25533d2553o{addingIV
ersaMNatiftle Wildingty,hcaw•tenantNatitumymcccsppppenibililYmnotifytWOrupmlattheIt
Ln it5.15333md1S5ilityW
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us,cmetpriortoas gyara me alloO patng,ll�j'
jignatureofApplicant Date
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All roof coverings to be Class ••B'• or better
�r ce authOriudagcnt am
Please check applicable subcontractors and complete the following information:
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SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
'1j
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
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CITY OF
UPEkTINO
CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN # _
Date:
Building Address: ,g I W7
C/
BUILDING
Owner's Name:
Phone #:
-Relocation of Furnace
- 3- S
Contractor: �. -hone: g0a- g -b f LS
License #:�
o/lfl�l� (J
MECHANICAL
Contact:
Phone:
Cupertino Business License #:
Building Permit Info:
Bld Elect Plumb ❑
N4ech Ef-
Job Description:...
Residential ELZ r Cornm#rcial ❑
Seismic Fee Res
For Residential Installations:
Attic ❑ I" floor ❑ 2"d floor ❑
Seismic Commercial
Adhere to min set back requirement ❑
or Commercial Installations:
Elec Permit Issuance
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
Mech Permit Issuance
New installation Planning Approval Required ❑
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Cost of Project: Type of Construction: pR
Occupancy group:
Plumbing Permit Issue
PLUMBING
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
❑ ❑
BPLANCHK
New Location Replacement
BUILDING
Qty. if
Applixle Fee 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
13REMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILIDNG
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
MPERMITFEE
Mech Permit Issuance
MECHANICAL
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PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING