05040042 CITYOFCUPERTINO
BUILDING DIVISION PERMIT .0 0NTRA&T0R4INF0RMATI0N
BUILDING ADDRESS: PERMIT NO.
RESIDENTIAL HEATING AND A/ IN 05040042
OW
NEWS NAME: PERMIT ISSUE DATE
ONE: SANITARY Q&kOL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
eO eLecr PLO O
Militia
O LICENSEDCONIAdmaderSDECLARATION Jo 1
I herby affirm Net I am Ikrcacd under proviuoa of Calner 9 fmmmense Is ��
with Section]q1U)of Division 3 of the Buvnessard Profruluna Code,and my license 4
in full forceande ft O Lag —1pS55N REPLACE FURNACE
j z L Arta 1
n Dau Constaswr S
tg ARCHr7EM DECLARATION V
'� rJ I understand my phw shell he wed u public records 100[
3 KKKo Lkewed Pmfeuional I B/� rl
5 OWNER-BUILDER DECLARATION
Com ION V
+�a I hereby.(Sere that 11. exempt from the Camranor's e:Any c law for tM
O O Whfollich ex reaeon. aeon t 7M tra r, Ito. and ..dem li Cale:Any city of county
$
Which rets is.•permit re cones the ate,,impma,demolish.m repair any uncture
Hsi pdwroits auanee.otos rcqulres the Applicator retrench permit bfile asigned wumanl
F<
that he is licensed pursuant or the provialow Of the Comrader"Limnm law(ChaPmr 9 Sq.Ft. Floor Area Valuat on
fF5F 3 (commencing with Section 7000)of Division 3 of the Boamom it Profesioa Code)or
IE .. that he Is emmpt therefrom aM doe bub fee the alleged exemption.Any violation of
Section 7031.5 by any applicant far a permit objects the applicant b a civil pmalrY of
got mom Nan Bse hundred dalt,ra(Ms . 3 7�er0 0 CCUpanCy Pe
❑I'm maser argils property,in my employee with way.As that,ole camp rmation,
willelo the work,and theawmure lenmmunded ea(rcred forsak(Sa.70114,Business Required Inspections
and Proksslom Code:The Cenumrar's Llan Law do.not apply b an ownere of tl P
property,who builds Or improve,mmcon,end who do.such work hlmalf w through his
awnemploycoa,provided dutsuch Impeasemenu art notha nded oraReW fwsals.If.
however,the building or Improvement Is mid within me)'car of completion,the owner-
Wildn will haw the burden of proving that M did not build or impmm for purpose of
ssk.).
0 1,as owner at the progeny am exclusively contnming with licensed conoaeun in
customer the project(Sec.7044,Business and Podeasiow Code:)The Conummr's Li.
orae law does not apply 0 an oweer of prepeny who builds or Improvs thmmn,and
who convects for such project,with a comostar(s)licensed puevant in the Contractors
License Law,
❑Iam.empt antler See .B A P C for mis mann
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby alarm under petalty of perjury one of the following declarmlew:
1 have and will maintain a CeNOcau of Consent ulf-humm for Warkee'sCompen-
selian,u pmvWed fa by Section 3700 of de,labor Cade.far 0t,performance of de
work for which this permit Is Issued.
0 I have and will maintain Worker's Compensation Iran==,u required by Section
3700 of doe labor Cade,fa the performance of the work for which this permit is lssa6
My Wo �ComppeMUM r�hisnsunna�� .Nnand Policy numbbeersm: Q�
Grier. 3 •v--CkT\O� Policy No.: M�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihisu:cdm need msbucomPleud If the permit is form=hundred do0an($IN)
or learn.)
1 certify That In the performance or the work rot which this permit is Issued.I shall not
employ anypmmn in any msaner an As in become subject to the Workers'Compenadon
Laws of Catifamb.Dau
Applicant
NOTICE TO APPLICANT If.after making this CcNOceu of Exemption,you should
become subject ro the Worker's Compensation previsions of the Labor Code,you must
7�'j. feMwidt comply with such provisions Or this permit Mall be decmcd revoked.
q O CONSTRUCTION LENDING AGENCY
(•" l hemby afaren don den IMa construction lending agency for the performance of
rL D the work for which this permit Is Issued(Sec.3097,Civ.C.)
aQ lender's Name
]z Lenders Address
[)Q I certify LOU I have rand W s appllculon and sue that the above Inf oreadun IM
ly career.I agree ro comply with all city and m
county ordlneea b
and sum Imn,relating
OE building construction,and hereby ambodm repmxnudw of this city u army upon me
aluvc-mendoned prupcny far iwpccdan purryus.
(We)agree to esu,indemnify said keep,harnkas de City of Cupertino aPiwt
y Rabilidesjudpments,costs ad expenses which may in any way we=against mid City
V 7 it consequence of the Amusing of this permit.
C APPLICANT UNDERSTANDS AND WILL COMPLY WITH.ALL NON-POINT Issued by: Date
SO CE REOULATIS W
Re-roofs
SiShAiture of ApplicanuContrabr J1 Dau
HAZARDOUS MATERIALS 01SCLOSURE 'Type Of Roof
Will the applicant in future building ottupsa,store in handle aerdow maurbl
a defined by the CupeN80 Municipal Code,Chapter 9.13,and the Hatlm and Safely
coda.secdam:ss33(.)7
❑Ye 4I 1 /No All roofs shall be inspected prior to any roofing material being installed.
T\ If a roof is installed without first obtaining an inspection,I agree to remove
Will the it ma su her future building bytheOccupant esu:equipment Qu her Mara which
it haeydna sit conWninenm u dennea by doe Bay Arca Air Quality Management all new materials for inspection.
iwic@
❑Yes )("i
I have r.J mearaNnusmamriatamyuimmenu unJer ChaPuri93 ofdoc Califor-
nt,H.lmd<Safety Code,Swd=75507.25533and25534.iun wAdIhBifdoc building
dean not currently haw:a unm.met It is my respowlbility ro notify to=up=,of doe
req mcnmwhichmun e�tp�da�n �a7wr�aa�n�cempwmarampmay Signature of Applicant Date
1 fu ' ' "" q.TZ� All roof coverings to be Class"B"or better
0........hodead agent Dam
Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone(408)777-3228
cl 0 Fax(408)777-3333
#UPER,TINO
Building Department
JOB ADDRESS. PERMIT #
o S'z �e c-� S° 2 _
OWNER'S NAME: (,t I PHONE # • 10
GENERAL CONTRACTOR �Q -h #
I am not using any subcontractors: 1 Y IOV u, LOQ. 14 ,-1
Signature Date
Please check applicable subcontractors and complete the following information:
63 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 Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Community Development
10300 Torre Avenue'
t, J. Cupertino CA 95014
!! Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEI�TINO
Building Department
~ JOB ADDRESS: PERMIT #
OWNER'S,NAME: Ll a I PHONE#_ Qa • b�
GENERAL CONTRACTOR: Al 1 Cyt # ✓�
I am not using any subcontractors: I✓ l.(/�OL 1 4 l�M,tl.f'14�. u •�
Signature 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 '
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock j
Tile a
Owner/Contractor Signature Date
CITY OF:CUPERTINO o
ainkma- FURNACE/AC D
SUPEkTINO PERMIT APPLICATION FORM
/ •, Date:
Building Address:.
103 I e_.rr \N
Owner's Name: Phone #:
Y in C1��na iSCk k - (_W(b) 3q lou3
ontractor: P one: License#:
estd-en 'i G0 \A-ea-�J R Inc. 3,-1-tio-t3 -1Z�S55�-I
Contact: Phone: - Cupertino Business License #:_.
br o_ los a1If- I
Building Permit Info: -:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description: .
Residential Ix -Commercial ❑ __.
For Re idential Ins allations:
ttic 1$` floor 2"d floor❑ `
dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Plannin Approval Required ❑
Cost of Pro' t: Type of Construction: - . - Occupancy group:
\ -11 S . 00
Strapped ❑ On Platform 0 Bonded ❑ 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
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING