03120020 I • CITY OF CUPERTINO §
BUILDING DIVISION P1 RMI'I' CONTRAC�TORINF.ORMATION
A � ,. .. _a
BUILDING ADDRESS: AAA FURNACE & AIR CONDITIO TWTOID3120020
0372 SCENIC
ERS NAME: PERMIT ISSUE DATE
;BELL TIM D AND ROBERTA J 1712 STONE AVE 12/04/2003
NE: - SANITARY NO. CONTROL NO.
(408) 293-4717
ARCHITECDENGINEER: BUILpING PERMIT INFO
BLDG ELECT PLUMB MECH
+Oo LICENSED CONTRACTOR'S DECLARATION O O O
1 hobby affirm that I am littnud under provisions of Chaplet 9(commencing lob Description
with Section 700X1)of Diviaio of NC Businea�anO Professions CtMe.and myliccnm is
+ � in full forte=rad ?'u3 CHANGE 100, 000 BTU FURNACE/& RETURN DUCT
j ? License Class Conti
F p Dam ComracC
Eqq wy it om whilTECTS p,p A ATIDN
2< I understand my plans.hal I be mcg a public rccmds
SoG LiccnsedPmfcuipnel FiIV,�
3 Oat I am eU him from
DECLARATION L�
<q I hereby maxo .(Sect that 11. exempt from the sionsCContractors License Law for the
p o following mason.(Section 703 1.3,Rosiness and Rofcssinns Code:Any city or county
5: which requires a permit m construct,alcor,improve,demolish,or repair any Structure nEc $3000
z� prior or its issuance,also requires the applicant for such permit to file a signed statement
22xs< 'hat he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area 2ROltation
2Fp (commencing with Section 7WD)of Division 3 of the Business and Professions Code)or
$ That he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7831.5 by any applicant for a Permit subjects Ne applicant b a civil penalty of
net mare Nan five hundred dollars($500). aney Type
I,u owner of the property,or my employces with wages a their Sale compensation,
will do to work,and the structure is not intended or offered for sale(See.7044,Business
and Professions Code:The Conleeemri License Law does nor apply to an owner of Required Inspections
property who builds m improves thereon,and who dors such work himself or through his
own employees,provided that such improvements we not intended or offered for sale.IL
however,the building or improvement is sold within one you of completion,the owner-
builder will have the burden of proving that he did not Wild of improve for purpose of
ulcJ.
❑ 1,as owner of the property,am exclusively contracting with licensed con orcbrs to
comuuct the project(Sec.7044,Business and Professions Codcy The Con=dor&Li.
came Law docs not apply to an owner of property who Wilds or improves domon,and
who contracts for such projects with a conmator(s)licensed pursuant to the Cnnvactors _
License Law.
1 am exempt under Sec. B&P C for this reason
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby arm under beauty of perjury one of the fallowing declarations:
lc.mbn
ave and will maintain a Certificate ofConum to self-insum for Worker's Compcm
,as provided for by Section 37M of Ne labor Code,for the performance of the
for which this permit is issued.
ave and will maintain Wrokeri Compensation Imunna,as required by Section
ofNc Labor Code,for the performance of Ne work for which this permit is burred.
roe ompe 3fl summa prier and Policy number ter Policy No..����.�y3i!0F;J n3
CERTIFIAT�OF %EMPfION FROM KERS'
COMPENSATION INSURANCE
(This Section need not becompleted if the permit is future hundred dollars($1(X))
or less.)
I certify that in the Performance of the work far which this permit is iuucd,I shall not
employ any person in any manner Sa as to become subject to tW Worker!Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICAT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit Shall be deemed revoked.
Z.~NrCONSTRUCTION LENDING AGENCY '
1 hereby affirm that there is a construction lending agency for the performance of _
• Y.
on,work for which this permit is issad(Sec.30,97,Civ.C.)
S 0 Under.Name
= z Lenders Addm.a
J J O 1 certify that I have read this application and Sunt that the about information is
coral.1 agree to comply with all city and county ordinances and smte laws relating to
�U building construction.and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Hy (We)agree to save,indemnify and keep hsrmleu the City of Cupertino against
h liaemusm,judgments,costs
ramiand of thismdrit. may in any my accrue against aid City
(„)? in canuymnce of Ne gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SEREGULATIONS.
I4/ 4e
y 121 D Re-roofs
mrc Applic UCFData
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant Sar future building e,Chapter
store 9.1 .handle hazeNuus material
Aladeflood by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Sector 25533(x)? All roofs shall be inspected prior to an roofing material beim
❑YIN C]No P P Y g g 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
dt hazardous air contaminants as defmN by'be Bay Area Air Quality Management all new materials for inspection.
iWria7
❑Yes ❑No
1 have mad the hamNnusmawrials mquimments under Chapmr6.95 ofthe Califnn
ni.l iffi&SafcryCode,Smc.255f15.25533and25534.1undersmndlhmifthe Wilding
does nor currently have a moan.thm it is my respomihiliry m angry th occupant of the
mqui ems which m u W met prior b issuance mf a Cenificam of Occupancy.
O _ Signature of Applicant Date
Owne,maumona dagenf Date All roof coverings to be Class "B" or better
U3 /zoo z o
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
/a —os�-o3
Building Address:
Owner's Name: Phone#:
Contractor: 4A4 F,,/,1 ru r A/c Phone: License#:
4 PAC, Z C oe-' e/;7/ G. 7/
Contact: y- ✓1 Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
C�t2y c DOOoo
ur
Residential Commercial ❑
For Residential Installations:
Attic ❑ 151 floor ❑ 2nd floor❑
Adhere to min set back requirement[-]
MW For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation . ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
O.Op
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A licable 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
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
'72-? 'Z