05050083 CITY OF CUPERTINO ° ' .� 5 _ 04"1
" '"''4 BUILDING DIVISION PERMIT tONria "TURa1Nvo04 T��!N,
.L,Fq-.��s;.tet.
BUILDING ADDRESS: PERMIT NO.
CONDITIONED AIR 05050083
4C) qTAPITr)RID DR
OWNER'S NAME: PERMIT ISSUE DATE
46/2
NE: SANIMARY OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDGO ELECT O PLUMB MFCH
O O
aoo that LICENSEDCONTRACTORS
underSDEOLARATION IOb Ilgsp� n
6 1 on by [to.Nat 1 am fdo llu undue pmvlslau of CCM IC. 9(commencing F
with Saban 701M1)ofDividon Sof the BuainwanO Profrssiou Codc.aM mylicenac le �®
Lin toil force MsOCIMA efQ tqy_ _ WHY, A/C '�g L
Z License ClassC—d�—Lk.g
O Dam 51 a 'or ARCHITERS DECLARATI N
ell 7
y I understood my plena shall he used as public menrm
and Licensed Professional
� �0 2005
g OWNER-BUILDER DECLARATION �'
P<I I hereby olnrm Not I A.exempt(mm the Communes License Law for the
y p 0 following reason.(Section 70115,Business And Profession Cole:Any city Or county
.sI$ which requires a permit to convect,alma impmw.demolish,Or mpair any structure
�Sr^ pow en its Issuance.also requires the applicam for such permit to flit a signed summent
F< that he is licensed pursuant the pmvisionenfthe Comrecmis Umnse Law(Chapmr9 Sq. Ft. Floor Area a sea On
Zp (commencingwith Section7MD)of Divlslon3of Oc Buainwand Profassivu COCe)or .
that he Is exempt therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant An a civil Pauly,of 3 hero 0 Occupancy Type
AM mom Nan It.hundred dollars
❑I,uowsner of the ptaporty,wmy nmploycea with wgesu thc'v sole tampenssdon.
will do thework,and theaaucenm Isnotimended proffered fwsam(Sec.7014.Business
and Profesdou Cod-The Contramoes Llceue Law deer nm apply in an owtmr of Required Inspections
property who bui lds or improws thereon•and who does s uch work himself or through his
own employes,provided that such improvements art not Intended aroQesed onsam.11.
however,the building or improvement is sold within one year ofcompletion.the owner.
builder will haw the burden of proving that he did not build or improm for purpose of
Mm.).
❑1,as owner of the property am exclusively contracting with Rearmed convertors in
construct the pmjca(Sec.7044,Business and Profession$Cade)The Contravenes Li.
cement Law COCA not apply in an owner of property who builds or Improv daimon.and,
who contracts for such projects with a comrutor(s)licensed purereal m LM Convo ctoem
I ire.Law.
❑I am exempt under Sec, ,B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby anion under penalty of perjury,one of tiro following declanOoCA;
1 haw end will mdntsin•CeNOcase of Consent m self-Warm for WodmfaCumpen-
137,00
an,u pmvided for by Section 3700 of the Inbar Cade,for the performance of the
rk for which Ni$permit is issued.
I have and will maintain Wor1r1s CompemWon Insurance,u required by Section
of the Labor Code,far the performance of the work for which this Permit is Issued.
Workees Compenution Inco.canter and Policy number arc:ller. t� �[ Iiry Na.:X14 -1199T
CERTI I ATE OF E% ON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section treed not hemmplcted lithe permit istarwe hundred dcIWA($101)
nr lean.)
I canify that in the performance of the work for which this permit is issued.I shall not
employ any ismem in my manner m as in become subject to the Workers'CompeasNon
Lava of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
became subject in the Warku's Cm,nouition ptuvislons of the labor Calc,you mtW '
0z forthwith comply with wen provisions or this permit shall be deemed remla d.
zt"' CONSTRUCTION LENDING AGENCY
[�► Ihemby Mrm that Nem is a conbruction Coding agency,for me performance of
6vi> the work for which mix Permit At lssucd(Sec.3(N7.Civ.C.)
W QIsMdces Name
0.aLondeesAddress
()C 1¢Nfy that I ham rod this application vol wen that me above information is
1rr
t cement..l agtto comply with all city and county ordinances and some laws relating to
0 VC building consuucdon,and hereby aumotim mpresenudv of this city to enter upon me
G37 .trove-mentiormd Property for iaspeetian PugmML
(We)agree to saw,indemnify and map harmless the City of Cupertino against
f/1 liabilities,Judgments,corse and expenses which may in any way accrue against Mid City
V Z In consequence of the gtMting of this permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO RCEREGULAITONS.
icL- a4, (�- SI /6b S Re-roofs
Z
ignmum of Appincani/C.Ameentor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant Mom or handle haurtlou material
s dcflncd by me Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Coom.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
13
❑Yes No
Will the applicant or future Molding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hancedou air contaminants u tm0ned by the Bay Area Air Quality Mangcment all new materials for Inspection.
a
I oOlsvip7
C]Yes NO
I have mad the taxations materials requirements under Chapter 6.95 of the Cabot.
nu Health&Safety Code,Sections 25505,33533 and 25534.1 understand that if the Molding
Jus not amenaly ham a mnanL that It ls my onpomibilky en may the acaupmt Of the
requi niswhichnues,W eI orAnI aneemReamafocMacy. SignatureofApplicant Date
K �ss n 5//6/O C All roof coverings to be Class"B"or better
O or eumorizetle cor Om
Community Development
10300 Torre Avenue
(Y Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT#
1 Aa o O ' 6 y sc-roo 8'3
OWNER'S NAME: PHONE # tio6 1- O
GENERAL CONTRACTOR: VrLj, AX # Yom 19M 1
f I am not using any subcontractors:
Signature Date
5 Please check applicable subcontractors and complete the following information:
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 T
Sheet etal
S&,--et Rock
Ale
er/Contractor Signature Date
: —
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# 2 l7 O lJ c Date: (J5 / /6 /05
)S / /6 l0 S
Building Address: 0 I t{
11 SAs ';Tar, � Sf .. Cti cti%no C`2 9S
Owner's Name: Phone #:
Karan tJ2rc> 1Z C o ) � -8S fig`
Contractor: Phone: License #:
C . .0 1 - 4yS169 -Cc2O
Contact: Phone: Cupertino Business License #:
`o►me s
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mecham
Job Description:
AM
a AIC
Residential(Z34 Commercial ❑
For Residential In,-�tt,allations:
Attic ❑ 191 floods 2nd 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 Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
It , 000
Strapped 0 On Platform El Bonded El Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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
EPERMITFEE Elec Permit Issuance ELECTRICAL
tl MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee 6 BUILDING
BUSLIC Business License 13,LUDING