05030183CITY OFCUPERTINO
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CUNTRAC,TOR,INF(J.RMAT.XUN..
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BUILDING DIVISION PERMIT
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bJILDING ADDRESS:
ty
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PERMIT NOb 5 0 3 0 183
OWNER'S NAME:
PERMIT ISSUE DATE
CI
ONE:
SANITARY OL N0.
ARCHITEcTiENrthrau:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
lb Description
rm 1 licensed cd under provisions of Chapter 9 (commencing
1 hereby affirm am
p
with Section 7") of Division 3 fthe Basin and Professinan Code. end my license Is
ILIc elm�asvdeH� Lk.d
REPLACE 2 HVAC UNITS'
Dam Coatraeler
CONTRACTOR: NEWCOMB MECH
ARCHITECTS DECLARATION
I understand my plans shall he used As public records
.
NO FEES FOR THE CITY JOB
Licensed Pro@WOW
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law far the
following moon. (Section 7031.5. Business and Professions; Cade: Any city or county
which acquires . permit to conurocL slue cep om. demolish, or repsir any suuetum
prior an its issuance. also acquires the applicant for such Permit to Ole a signed moment
he is licensed Connector's IJcenc Law (Ch 9
Sq. Ft. Floor Area
Valuation
that pursuant in the provisioes of the apt
�trn+
�'t
(commencing with Section700E) of Division 3 of the Butoasam!Pmfrssi.. CoM)or
'�,---J
7
that he Iso.
exempt '^from atm the bub run the alleged evmpdon. My vloluion of
/ I " !t/40
,\ APNh'Nur[/Ibel' (%1
_ 1 Occupancy Type
1
Section 7031.5 by arty Applicant far a Permit subjects the applicant an . CMI petnity of
hundred
5arployca
,amy1.
{(T�
01, nownrofNepropenywith wagesss theirmle cooperation,
�( I.+
,�--.�ss
1tT f7Yp98 tlOns
will do me warkand the structure ts mlimmaded oroRered fart= tsa. lawn. Besirmss
Nd Proressimts Cade: The Canuaem's License law does not apply m an owner of
p
property who builds orimprovn Rteten, andwhadoesauchwmk himselforthrough his
'
own employees. provided thatsuch improvements as naninuMW oroffered for We. If,
i
however. the building or impromment issold within me year of compl.bux the
builder will have W burden of proving rine he did at build or Improve for purpose, of
sale.).
0 1. As owner of de, prepay, am tial Wvely contracting with licensed contnaon w
consumer the project (Sec. 7064. Btulness and Professions Cade:) The Comrscbr's LI-
cense law dors not pply an an owner of Property who builds or Improves thetean. and,
who contracts for such projects with a eamu ctor(O licensed pursuant an the Comeacmrs
License Law.
O lamaamptunderSee ,B&PCrorthisreuon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby arfirmunder penalty of perjuryaro of the following dedarNou:
Worker'aComp-
I Mw and will maintain aCeNfiau ofConsent to selhiesure fm cn
satlon, u provided for by Section 3700 of the labor Code. run the performance of to
wort for which this Permit is Issued.
0 1 ban and will maintain Workers CampenNon Insurance, As required by Section
3700 of the labor Code, for the perfoma cc ofthe work for which this Permit is issued.
My Workers Compensation Insurance cagier and Policy number sac:
Cara Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sabre need not a comploud lithe permit Is fmane hundred dollen ($ I W)
an kala)
1 « oily that In the performance of the work for which this permit is Issued, I shall not
employ any person in my mm scra u m become subject to the Workers Compensstlon
Lawsof Califomla. Wu
Appllcod
NOTICE TO APPLICANT: IL after making this CcniOcam of Exemption, you should
become subject an the Woreari Compcnation previsions of the Labor Code, you must
faMwith comply with such provision or this permit shall be lamed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby a1Rm that mere Is a construction lending agency for the performance of
Ne, work for which this permit Is issued (Sac 3097, Civ. C.)
Lmndces Name
Lenders Address
I certify that 1 have mad this application and aura that the above Informadun Is
ComcL 1 agree to comply with all city and county ordinances and sou laws relating to
building conawcuon, and hereby autham representatives of Nie city to enter upnn the
above-mentioned property for inspection purposes.
(We) agree in save. indemnify and keep harmless the City at CupcNOO against
liabilities, judgments, costs and expenses which may In my way aCcom against mid City
in consequence of the flooding of this permit.
APPLICA -kW RSIANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR EGO ONS.
Issued by: Date
Re -roofs
_
��y�
Sifl of ppltanVC Dau
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building aaupandstore or handle hmsrdaus material
u de0ned by the Cuperdno Municipal Code, Chapter 9.13. and the Health and Safety
Carlo. Section 255320)?
No
All roofs shall be inspected prior to any roofing material being installed.
OYa
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or furore building occupant use equipment or devices which
It htnrdon air conuminmts As dii1sand by the Bay Arta Air Quality Management
all new materials for inspection.
Istria?
OYes ON.
I hem read the humbler, materials requirements under Chapmr6.95 onhe Califon
nh Halth&SafctyCode.S=d=255W.25533md25534.1 underatsM lhm ifthe building
dam not cumn I by 4 in it u my acapmau ility 0 sadly the oaupert of the
requlremcntsw edpiardal4Lugpceance�^Ocamo> Patty
Signature of Applicant Date
((//r-
All roof coverings to be Class "B" or better
owner ar aathanvcd. Int Time
IU PEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
APN #%� o Z Z_
Dater_ ��_ OS,
Building Address:
2lll� Sle✓en5 C�'c•e ('(
BUILDING
Owner's Name:
C Cv pe/' I 1 no
Phone #:
QS' 777-327(
Contractob eL) Mer—k- Phope_a .573-2139
License #: / cl q 35 p
Contact: Phone:
4� ( o�, b
P Nev�
Cupertino Business License #:
Building Permit Info:
MECHANICAL
BREMAIRHAN
Bldg ❑ Elect Plumb
Mech
Job Description: R L f) CC: -r -4 0 I w /j 7S
- S{ytiy; -►J X3'1 !f h}TS
Residential ❑ Commercial
ELECTRICAL
For Re idential Installations:
f ❑
BSEISMICRE
ttic I" floor 2"d floor'
BUILDING
dhere to min set back requirement ❑
/ BSEISMICOM
or Commercial Installations:
Replacement same weigh Additional weight (structural calcs) ❑
BUILIDNG
Structural Calculations required for new installation ❑
EPERMITFEE
New installation Planning Approval Required ❑
ELECTRICAL
Cost of Project: Type of Construction:
Occupancy group:
Strapped ❑ On Platform 0 Bonded ❑
Sq.Ft. Floor Area:
❑
PLUMBING
New Location Re lacement
Bldg Permit Fees
Qty. if
Annlirahle
Fee m
Fee Descrintion
Fee Group
J � ,
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
/ MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPLANCHK
Plan Check Fee R
BUILDING
BUSLIC
r ,ems--,
Business License9 ,
..�
BUILDING
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