04040138 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTnR INTOILMATIQN
BUILDINGADDRESS: RMCI BUILDERS PERMITNG04040138
251 SIEVENS CANYON RD
OWNER'S NAME: PERMIT ISSUE DATE
LYDIA TRIANO
NE: SANITARY NO. CONTROL NO.
(408) 988-2544
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
I� M t� Q
Bop LICENSED CONTRACTOR'S DECLARATION I Job Description
co I hereby affirm that 1 am licensed under Provisions of Chapter 9(commencing P
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
o in mB farce and`f REPLACE FURNACE
D n:5 License e I
Lie.X
Dart Y� Canvacmr
e ARCHITELTS DELLA
y 1 understand my plans shall be used as public mcnr.
JaU
g
Li
o cense)Pmfcssional
OWNER-BUILDER DECLARATION
iY I hereby affirm on 1 1. exempt from Nc Connector's License Law forte
i❑O following requires
a.(Scion 1113L5,Business and Pntfdemolli Code:Any city or aunty
$ which its a a issuance,also re unmtmcL alter,improve,h permit t or repair any sVueturt
poor—Zs that cosheredforman,to res the provisions
forthe such natemcm
ggxxSI 600
O lhathcencin withSemantmNepmvisimm�fordueBnromanmaacl�o(Chapter 9nsCode)or Sq. Fl. Floor Area Valuation
yF
(commencing cssand Professinnv Code)or
y�� tel he Is exempt Ncmfrom end the basis for the alleged cxemptlon.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant in a civil penalty of 34%TN6'QI"cr00 Occupancy Type
not more than fine hundred dollars(5500). ' P Y YP
❑huowner of Ne properly,or my employee with wguas mm" pen Eon �r
will Pr thework,ands: swctumiatoHtn kende orofferedfor e(Sec,7 t
end Professions Cods,:The Contractor's License Law dace yf a r i ;_ Required Inspections
propeny who builds or improves thereon.and who doesmch work t ug h r
ownemployee,pmvidcd tauuch improrcmenu vs,noen¢nded aroRere orale)
however,Ne W ilding or impmvement is mld within one yeu of completion,Ne owns
builder will have the burden of proving Net he did not build or improve for pmpasc or
sale.).
❑1,as owner of Ne property,am exclusively contracting with licensed convectors to
conswct the project(Sec.7044,Business and Nofeuiom Code:)TW Conmctar's Li.
come law does not apply to an owner of property who builds or improve thereon,and %
who contracts for such projects with a contesctar(e)licensed purauanl to the Conmehor. /
License Law.
❑l am exempt under Sec. B k P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby arm under Penalty of perjury one of the following deductions:
1 here and will maintain a Cenif¢om of Cotue I to selblomme for Worker's Compere
sation,as provided for by Section 3700 of the Labor Code,for Ne perfonnana of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the LaborCotle,for the perfarmence of the work for which this permit is isswd.
Cx My Workeh Compensation hummoce carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TAH section need not becompleed If the Permit is for one hundred dollen(SINN
or les.)
I certify Nm In Ne olmmee of Ne s heir this permit H issued,I shall nut
employ any p, 1 nyry s mbjcetotha Workers Compensation
Laws of Calif DoY
Applin I
NOTICE OAPPLIC :IL after making the eniacase or Exemption.you aAoui1
become subject to the Worker's ComPenation previsions of the Labor Code,you must
,Jz forthwith comply with such provisions or this Fermi l shall be deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
t—t 1 hereby arrest Nat there is a construction lending eScncy or the performance of
1.► the work for which Nis permit is issued(Sec.IND.Ci,C.)
W Q Lenders Name
z Lenders Address
U Q 1 cenify that 1 have read this application and slate that lAc above information is
Dw P correct.l agree to comply wit all city and county ordinanns and state laws relating to
0U building consuuetion,and hereby authorise mpresentatim of this city to enter upon IN
W ehovc.mcntioncd Fmpcny for inspection proposes.
gy (We)agree to save,indemnify and keep harmless the City of Cupertino against
i—t fA liubililies,judgments,costs and expenses which may I anyway seems,against said City
U Z in consequence of the granting of this Permit.
^ APPLICANT ERSTANDSAND WI PLY WITH ALL ON, INT Issued by: Date
SOURCE U ATIO
Z/ Re-roofs ��
_ she cor ApplmaHAZARDOUS
A or" Onto
III esinNfor. MATERIALS ,mCcmban Type of Roof
Will Ncapplicant ar forum Wilding occupantctmeor handle Heallousmaomiil
az toned by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
otic.Saenes 25533(.)1 All roofs shall be inspected prior to an roofing material being❑vs,, ON. 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
it huaNnus air comamimmur u defined by the Bay Arca Air Quality Management all new materials for inspection.
oricR
❑Yes 0 N
Ihave rtW the haraNresmmcriabwuntkrCluptarb.95oftoCalifonnia Hou'" afrely ,Sceduas 35505,2l4.l unds,ratmd Nuif lire Wilding
doe not carte a tcnent Net it isility m nou. the i-open (thc
rcyuireent hie nmt tp' rhteriflemeaf0cc sto
Signature of Applicant Date
wn .enanmaa ,m All roof coverings to be Class "B"or better
F Community Development
4 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRE S: 1
10-TO ( SreVWS CAUL0IV IZQ; rc #
OWNER'S N P #
GENERAL CONnACTOR. FA
#
I am not using any subcontractors: / cJr
Signa Date
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 z27
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Coac or Signature Date
CITY OF CUPERTINO �(3�
FURNACE/AC
�UPER,TINO PERMIT APPLICATION FORM
APN # ObDate: Z/
Building Address:
S UN
Owner'sName: Phone #:
6v61A ice / P\1U -Ib2 - 3/�
Contractor: / ��-� Phone: G 8� �/� License#:()'lZ�
Contact: Phone: Cup rtino Business License#:
(408, 3Z10� �f�Z
Building Permit into:
Bldg ❑ Elect ❑ Plumb ❑ Mech 1�
Job Description:
LlUs7//VG GE/�/T✓Lr4C f I�rLN4G
Residential Commercial ❑
For Re idential Installations:
Attic M 1't floor ❑ 2nd floor❑
dhere to min set back requirement❑
IN or Commercial Installations:
Replacement same weight ❑ Additional weight(structuralEl calcs)
Structural Calculations required for new installation
New installation Plannin Approval Required ❑
Cost of Project: Type of Construc ion: Occupancy group:
!(���� G�✓ U/oo(J F(LWL SING: F4m)t
Strapped ❑ On PlatforiijD onded L1 Sq.Ft. Floor Area:
New Location ❑ Re lacement
Q • 'f
A lipabje Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfin 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 BUILDING