03080050 . I-&OR CUPFWI'INO x�
BUILDING DIVISION PERMIT 4CONTRACTORINFORMATION
961LDING ADDRESS: SCHAUMANN AIR CONDITIONING PERMIT'003080050
20101 SOMERSE7 DR
OWNER'S NAME: HEATING & PLUMBING INC PERMrrLssDEDATE
FUJII HAYAMI AND PHYLLIS TRUST 08/12/2003
ONE: (408) 428-0640 SANITARY NO, CONTROL NO.
-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MPH
0 0 0 0
fop LICENSED CONTRACTOR'S DECLARATION IOU Description
Iu C 1 hereby affirm teal 1 am licensed under provisions of Chapter 9(commencing p
lbs with Semion]gl(17 of Division)of the Busincaa and Prafassinm CnhN.and /Y-
Dole
Hereto sa
ash Lfaumreean acct. nJ en L : REPLACE FURNACE F1 IV n B P�`+w
License CWsa .7C- l Curr
sF Dam cY / my Cuntranar
ARCHITECTS DECLARATION
1 I unticrstanJ my plain shall W used u public rtroNs P
>U oc I z ' 40
o t; Licensed Portent nnal
'N3 OWNER-BUILDER DECLARATION
ja S 1 hereby affirm that I am exempt from the Cnnnanor's License Law Ico'ar the W `p�i�
p o following cases.(Section 7031.5,Business and Professions Code:Any city or unty R'1'Lo1a
5$ which requires a permit to construct.alter,improve,demolish,or repair any structure $3020
_I< prior in its issuance,also requires he applicant for such permit to file a signed statement
that he is licensed pursuant to the previsions of the Contmaori License Law(Chapter 9 Sq. Ft. Floor Area Valuation
E
0 (commencing with Section 70(y)of Division 3 of the Business and Professions Code)or
Q that he is exempt Champion,and the basis for she alleged exemption.Any violation of - 3 6 9 3 O O O 2 O O
Section 7031.5 by any applicant for a proton subjects the opplicanuo a Civil Penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
I,as owner of the property,or my employees with wagea as their sole compensation,
will do to work.and thesracmre is not intended or offered forsale(Sec.]Ds4.Business - -
and Professions Code:The Contractor's Liceue law does not apply to an owner of 303 - ROUGH t�MOWRGns
pmpeny who builds or improves thereon,and who does such warkhimself or through his L
own employees,provided thatsuch improvements see notinlended oroRered foraalc.If. 304 - ROUGH ELECTRICAL
however,the building or improvement is sold within one year of cnmpletien,the owner.
builder will have the burden of proving that he did not build or improve fur purpose of 505 - FINAL ELECTRICAL
side.). 507 - FINAL PLUMBING
❑I.as owner of Ne progeny,am exclusively contracting wish licensed convectors to 508 - FINAL MECHANICAL
convect the project(Sec.7004,Business and Profusions Cade)The Contractors Li.
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects wish a eontraemr(q licensed pursuant to the Connecters
Lkenu law.
❑I am exempt under Sec. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of point'one of the following declarations:
I hoe and will maintain a Cenificme of Consent I.self-insuu for Walker,Compere
inion,as provided for by Section 3700 of the labor Code.for de,performance of the
wort for which his permit is issued.
XI have and will maintain Worker's Compensation Insurance,ss requited by Section
W of the Labor Code,for she performance of she work for which this Permit is issued.
My Worker'ef-Cum
�pensal' nlnaumnce carrier and Policy number are:
Carica:-/s[ % C_ y/ Policy No.:yG '/CL%tA 41 el
CERTIFICATE�PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becumpleted if the Permit is foronc hundred dollars($)1X1)
,it Itis)
1 certify that in the pc,furommed of Ne work for which his permit is issued.I shall net
employ any person in any manner an IS,to heeome subject to the Workma Comperuation
Laws of California.Dan
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Worker's Compereadon provisions of the Labor Cede,you must
.,O forthwith comply wish such previsions or this permit Shall W deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
(-. I hereby affirm that there is contraction lending agency for the perporman¢of
y'7
the work far which this permit is issued(Sce.)(197,Civ.C.)
(al 0 lender's Name
5:) z Lendcr's Adiress
dus
U O 1 certify Nat 1 banned thisapplication
and county
and states and
above sus missing is
It' F bonen.1 agree to comply with all city end scums roatim of and stain laws relating e
U show-mennauuctiooand homey authori WWWS.matiass a(Niscity to enter upon the
LLl shove-mentioned properly for inspection purposes.
gy
Wo)ague to cors,indemnify and hick harmless the City of memo
against
N incasual casualness
of the
uang expensof this Permit. may in anyway accrve vgainst said City
U z AcPLICA T ofshe granting of this permit.
APPLICANT UNDER- ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 URCE REGULATIO -
aa Re-roofs
r+' natureof Applicaactor
HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future Wilding meupam store or handle hvaNuu material
Sir defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
code, I-I enzss3z(a)+
❑Yes �I,.t No 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
it hazardous air commonness u defined by the Bay Arca Air Quality Management all new materials for inspection.
ln!aHulffi&WciyC�,&cdons25505,25533md25534.lunwm=dNetifft
strict?
❑Yes No
I have read she hmaMous materials requirements under Chi mmr 6.95 of she Califnr.
Nc Wilding
es not currently haw a sinam,that it is my resunsihility w scary the occupant of tWcimments wh m ee et prier to iauanee cera CemBeatearaegpmey. Signature of Applicant Date
(4; w -�� 9• a9-B3
ncr,ra arohorircd ogees Date All roof coverings to be Class "B"or better
%� -, 1— —
CITY OF CUPERTINO
FURNACE/AC
OF
CUPERTINO PERMIT APPLICATION FORM
x APN# Date:
3(v 9 30 O Z O —/Z-03
Building Address:
2,0 i e vim!
Owner's Namq: Phone#:
FtAXII7 -
Contractor: Phone: yog y23 — License#:
C SOM 7700
Contact: e'l 1J Cupertino Business License#:
0 5! 6 5
Building Permit Info:
Bldg ❑ E ct Plumb ❑ ech
Job Description:
Residential tv Commercial ❑
For Re idential In tallations:
Attic LJ 151 floor 2"d floor❑
Adhere to min set back requirement[]
For Commercial Installations.
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planni val Required
Cost of Project: o20
2 Type of Constructiotik 4 Occupancy gro :
Strapped 6n Bonded ❑ .�-• Sq.Ft. Floor Are .
New Location ❑ Re lacement
Qty .f
A b Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace . MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAMIAN A/C Units <= 10, 000 cfm MECHANICAL
LU BREMRECEPT Rec tl, Switch &Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERM=E Elec Permit Issuance ELECTRICAL
MPERMTFFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
? — BUSLIC Business License BUILDING
rT
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