05010054 'CITY OF CUPERTINO '3 W'
BUILDING DIVISION PERMITGONTRACTOR�INFORIVIAU
BUILDING ADDRESS: PERMIT NOO 5 010 054
T17R STAR ORD DR
OWNER'S NAME: PERMITISSUEDATE
Igh WILLIAM MANNION 01/10/2005
4FONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j00 LICENSED CONTRACTOR'S DECLARATION :lib Description/
1 hereby aMo.the,I am licensed under provisions oT Chapter 9(commencing `. 1 p o'+
zl with Section 7000)Of Division 3Of Ne Bass.and Profession Ccde,md my license is
j nimm�mmeaderreat. , �. REPLACE FURNACE
Z License Clu Lic.N
7 J Dab Co"Bic
e ARCHrtECi'S D"BEC AT N
t l understand my plansehall W used a public records
O OJ���
t G Licensed Professional - J
OWNER-BUILDER DECLARATION
M I hereby affrm that 1 am exempt room the Conusctor's License law(or the
00 following mason.(section 9131.5.Business and Pmfesdon Code:Any city arcounty
$ which requires a Permit to construct.alter.improve,demolish,nr arab my&[=turn $2000
a " prior to its iuuanec,also requires he applicant for uch permit to File aligned statement
< that be I,licensed pursuant mthe pmvisionofthe Contrubr',License Law(Charter 9 Sq.Ft. Floor Area Valuation
,Sp$ (eaouna,mng with Scodon7000)of Division 7 of the Busiresamd Profeuimis CMe)m
3 Nu to is exempt Nemfom and We bull for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects be applicant to a civil penally ofet0 0 Occupancy Type
not mart than five hundred dollen($500).
❑1,u ownu althe pmpeny,or my cmploym with wage u their sole companudon,
will do Ne work,and theauctam isnatinbnded or offered forsale(Sec.7W.Business Required Inspections
tad Ra(eu11 Code:The GntncmM1 Llama Law dose not apply u an awns of q p
propeny who Wildsarimprowa thereon,and whadoessuch work him rtforthroughhis
Own employees,provided that such improvements was not intended orafremd for isle.IL'
however,Ne building or Improvement Is old within one yen of completion,the owmar-
Wilder will have the burden of playing that W did not Wild or improve for purpose of
ulcJ.
❑1.as Owner of the properly,am exclusively terming with licensed conuamort in
construct be pmjecl(Sec.lOaa,Business and Pofeuiam Cade:)The Conoacmr's W
cause law does not apply ou an.vena.of property who Wilds or improves thereon,and
who contracts for such project,with a contactor(l)licensed pursuant m the Canuadori
License Law.' -
❑IamexemptunderSec. ,B k P C(or Nis reamn
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby a film under penally of perjury one of the following declarations:
I have and will maintain a Cerdncale or consent b ulf-iuum for Workei.camper-
ution,u provided for by Section 7]00 of de labor Code,for the Performance of the
work for which Nis permit is inued.
I have and will maintain Worker's Compensation Imuran.,u required by Section
of the labor Code,for the Performance of the work far which this Permit is issued.
My Workee )K ufa Into nm carrier and Policy number am:
Clot
nn: A19/19d32
CERTIFICATEOF EMPION FROM WORKERS
COMPEN ATION INSURANCE
(rds,ectlm need not he completed little Permit 6 fmow hundred Mllan(g 100)
n lea)
1 certify that In the performance of the work for which this permit is issued.I shall not '
employ any PrAmn in any manner an As b Wmme subject to IM Wafkeri Compennion
Laws of Califamis Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenlficab of Exemption,you should
become subject to the We&"',Compensation I mvialon of the IaM Code,you must
7z foodwlth comply with such provision or Nis permit shall W dccmccl mvokcd.
ti CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a constriction lending agency for the performance of
x the work for which this permit Is issued(Sec,7097,Civ.C.)
YQ larder's Name
5 Z Lenderi Addw e�f
J Q 1 mni(y that I have read this application and slate that the abow information u
correct.I agree is comply with all city and county ordinances and sue laws misting to
^, Wilding construction,and hereby authorize rePresentrom of Nis city b enter upon the
Ig1 AWve-mentioned property for Impaction purposes.
(We)agree to ave,indemnify And keep hnmleu the City of Cupertino agaWt
Tan' Iiabllities.Judgme ts.cats adexpenes whichmryln mywy acne apinl uid City
J in consequence e 6 ting of this 'L
SOU ICA E UNDE Iq5 NDE ANP W LL COMPLY WITH ALL NON-POINT Issued by: Date U
��L Re-roofs
Signature of AppluanVComauor Dam
HAZARDOUS MATERIA DISCLOSURE Type of Roof
Will the applicant or future Wilding ort ul atom or handle loaNaus material
u dennd by the Cupenina Municipal Cade,Chapter 9.12,and the Health and Safety
AELErack.secdea 75572(a)7 1/I All roofs shall be inspected prior to any roofing material being installed.
❑Ya ID�u
Will the applicxm o ruwm building oaupem use equipment ar Jevias which If a roof is installed without first obtaining an inspection,I agree to remove.
It harudnus air contaminants as claimed by the Bay Area Air Quality Management all new materials for inspection.
inrietT
❑Yes u
I have madd,huard� .menials requirements under Chapter 6.95 of the Califon
ria HnithkS ty COde.Seen, ).77 and ZSSN.I undcrsland thml(the Wilding
does not cu dy a¢nen4 t it is my sesPonihility to modify the scup n,n(the
A isle els bemm dorb ssunmearaeerdncab rocmpaey. Signature of Applicant ' Date
Owner to
amhe,, egem Date All roof coverings to be Class °$°or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: 1 PERMIT #
R. 050 / bo5
OWNER'S NAME: '/ PHONE # -25.
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
RI SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical � 7.23/57
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
T' e
Owner/Contractor Si tune Date
CITY OF CUPERTINO _
aC10FFURNACE/AC S� ( � vRINO PERMIT APPLICATION FORM
APN# / Dat
Building Address:
d i
Owner's N Phone#:
J n.iar, . o
Contractor: Phone: icense#:
e 8 / J 55 7 Z 3/ �b0
C ntac `J e Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
Residential,jj omme cial
For Residential Installations:
Attic ❑ 151 floor ❑ 2nd floor❑
dhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation PlanningA royal Re uired ❑
Cost of Project: Type of Construction. Occupancy grou
Strapped On Platform 11 Bonded ElSq.Ft. Floor Area:
New Location ❑ R laceme
Qt3 .
Appfic4bil Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREEMAIRHAN 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License DING
( �7 .
CITY OF CUPESITINO ��NTRA, TnR TN' (aj(t NATION't:BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT N004 110 13 5
79 STAFFORD DR
ER'S NAME: PERMIT ISSUE DATE
SANKAR SUBRA4ANIAN 01/18/2005
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLM ELECT PLUMB MECH
o 0 0 0
joo LICENSED CONTRACT'OR'S DECLARATION' '
I hereby airrm that]ram licensed under provisions of Chapter 9(commencing Job Description❑ Aggf
withSoction70CKBOIDivisio3 ofihe Busiressand Professions Code,and my license is �. �S1
n<�„
in cert mine and errePt. ADD 599 S FT. u U 1 1 ' �I _n
„O Dec.
Clus Contractor ` 4 ti t I'�'
'u$yl (MS & REMODEL)
f ARCall ba
DECLARATION � y
I understand my plain shall he used u Public records
/
eWs' Licensed Professional
yG OWNER-BUILDER DECLARATION
9yf I hereby
alTnm
that I am exempt from the Contractors License Law for the rI' vi r
COO following reason.seeuun7031.5.Business and Profession Code:Any city or county l'les � 'I %'I(�`•���
COO
lv which requires a permit W construct,alter.improve,dcmoluh,or repair any atruclum
Zj, prior to its iuuabec,also mquires the applicant for such permit to file a signed statement
< That he is licensed purconi to the provisions of the Comraiat's License Law(Chapter 9 Sq.Ft. Floor Area Val$&IWO 00'
22 0 (commencing with Semon]")of Division 3 of the Business and Prorsssions Code)or
r, $
that he u e uma,i therefrom and the beau for the alleged excmpdon.Any violation of
Section 7031.5 by any apPliam for a permit objects the applicant to a civil penalty of APN Number Occupancy Type
and morn done five hundred damn($S ). P Y YP
❑I,uowpv of the 36211023 . 00
propeny,or my employers with wagetes theirsolc compensation,
will dr fewmes sad the he C.roisme,License Law
does
apply to an Business Required Inspections
end property
Cade:The.iMmars rel had..
law dins not apply lf an owner of q p
properlywhobuildsviimproves himrandwho donsamh woh himselfarthrough his
own employes,provided that such rat is old within
arc not intended aramrW for tile.If.
however.the building or Improvement is sold within one year of completion,the owner-
builder will have the burden of proving WI he did not build or improve for purpose of
k.l.
.u owner of the properly,.B..elusively Professions Cod licensed mnmctora U.c wet the project(Sec.]064,Business and Professions Code:)The Conuacmra Li-
cense law dors not apply in an owner of property who builds or improves themen,and,
who conmets far..
ar such Projeca with a conuscou(s)licensed puraaof w the Contractors
License law.
❑I am exempt under Sec. B k P C for Nis moon
( T Dae
ON DECLARATION
1 hereby aEiw under penalty of perjury oro of the following duchustiou:
1 Wm and will rommaln•CerdficamafCon,ent to self-imum for WorkefsCmopcn-
ution,uprovided fm by Smdm]]Oil of the labor Cade,for We performance of the
work for which this Permit is issued.
❑1 hem ant will maintain Workers Compmedidon Iruurana.u required by Section
3700 of One Labor Code,fm the pcefmmave of tie work for which this permit is Weed.
My Workers Compewtion Insurance curie and Polity number are:
Carrier: Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS' . .
COMPENSATION INSURANCE
- (Thh rccrbn reed m Ne mpleted if the Permit is for ane hundred dollar(SIM)
or lase)
I certify thin in the performance of the work for which this permit is lured.I shell not
employ any reform in any mannas as ha becanesubjecuo lie Wmkcti Compemation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject 10 the Workers Compensation provision,of the labor Code,you must
Oforthwith amply with such provisions or this permit Mall be deemed mood. -
�'y CONSTRUCTION LENDING AGENCY
1 hereby affirm that dem is a construction lending agency rot the performance or /
Y,> the..,it for which Nu permit Is issued(Sec.3077,Ci,C.)
31 Q Landers Name
z Lender's Address „
U Q I cenify that I bent rad Nis application and rete that the above Information it
.T, F correct.I agree to comply with all city sad county ordinances and sum laws mhting W
0 U building construction,and hereby sulhorine rcpmenutims of this city to enter upon the
a above-mcntiuned properly for iuPmtian Pugmsea
(We)agree to save,indemnify and keep hamtless the City of Cupertino against
In liabilities,judgments,costs and Ceram,which may in any way accrue against said City
U 7 in consequence of the granting of this Permit. ...
F7 APPLICA U ERSTAN S A 0 WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC R ATIONS. I
a' Re-roofs
S�gbnuh ApP ran o t D 0
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building Occupant store or handle hevudous material
sa dented by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.sed10n 25532(a)7 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes f N P P Y g g
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 ha'modon,air contaminants u defined by the Bay Arca Air Quality Management all new materials for Inspection.
District?
❑Yin AN. '
I have mad the harardms materials requirements under Chapter 6.95 or the Cali for y
ria Fkal sr Safely Code,Sections 25 5,25533ud25534.lundemm�dthmlfthebuilding
dins ort by hem a tenet,that s is my map onsihility W nmily Ila occupant of the
rcqui en bellMost W pd LOissuance or.Deforested lGCea ey. Signature of Applicant Date
wnGr awharizc0 agent O D m / All roof coverings to be Class"B"or better