04060212 77
CITY OE CUPERTINO0 IIN eORMATION`..
BUILDING DIVISION PERMIT ,_ . ,, R.._�.,,,,, , ,•..,
BUILDING ADDRESS. AAA FURNACE & AIR CONDITIO W�904060212
10164 V PORMTT I�UHDATE
OWNER'S NAME:
PAULA KLIEN 1712 STONE AVE 004
NE: SANITARY NO. CONTROL NO.
(408) 293-4717
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
HLDGELECT PLUMB MECH
p ops vV o 0 0
alOp LICENSED CONTRACTOR'S DECLARATION Job Description
UW 1 hereby affirm Net I an,licensed under provisions of Chapter 9(commencing
with Sution7"of Divu.m,,3ofdu Busine rofcasionSCotlo.end mylicenx is
5a� rmm�m n eb ue.x 7 REPLACE FURNACE & ADD A/C `��
2 Lkenxt ,Ppp�y
=p Dam Contactor d e
A CHITECTS DEC 1 N 'Od'p peo
A
1 undeaun my plans shall W used u pull Ns ® 07
DyU
3p,r} Licensed ProfessionalBOJ OWNER-BUILDER DECLARATION
<2 1 hooth,am affirm mat 1 tree exempt from the Contractors o License Law for the
i po O which re reason. emit t 703 1,5,Business and are,do Protections Cale:Any city of cc my
4100
Or which its men a permit to quires do, alter.improve,demolish. fl repair any svumum
Fly priormiuiensedpalso centto ftprovisions of for sub Coraco tor'& mmac, aw9 VHIUHII00
ned stawment
mohe mmeningwit pursuant omc of Division
ivisionl oft Conusinessnd Professions
(ChaptersCode)or Sq.Ft. Floor Area
s (eat he
(commencing with Saction and
of bads frnftheeusineemp on,AnicoaCode)or
� .. than he is emmpt sMre(rom end dte barb far me alleged Gumption.Any violation of
Semon 7031.5 by coy applicant for a permit subjects the appiicmt o a civil penally of e10 0 Occupancy Type
not mom than Eve hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their ack COMPenadon,
will do the work and the structure is not intended or offered for sale(Sm.7044,Business Required Inspections
and Profwions Cade:The Contractor's License Law docs not apply o m e Owner of 9 P
pmpany who builds or im preves menton,and who does uch work himself or through his
awn employees,provided than such improvements are notimmnded Oraffem l formic.IL
however,the building Or improvement is sold within one year of mmpletion,the owner.
builder will have the burden of proving Out he did not build or improve for purpose of
sale.).
❑I.as owner of the property,am exclusively contracting with licensed courtrooms to
comtmm the project(Sec.7044.Business cad professions Code:)The Contractors Lt.
come Law does not apply to an owner of property who builds or improves thereon,and t
who contacts for such projects with a convector(&)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. ,B A P C for this moon
Owner Dem
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent o self-insure for Warkcr's Compon-
. ion,as provided for by Section 3700 of dte labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
3]00 Utica Labor Code,for the performance of the work for which this permit is burned. '
M Werke s am nseti Insuanm Cartier and it number am: n
My
er. aE IFICA .OF PXEMPnONy�%13""W� �J
COMPENSATION INSURANCE
(Tib section auction he completed if tbe permit is fm one hundred dollen(51(10)
tar lC9a.)
I ecnify that in the performance of the work for which this Permit is issued,l shall not
employ any person in any msnneru as to become subjecumhe Workers''Compensation -
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making thb Ccniftcme of Exemption,you should
become subject o the Worker's Compensation provisions of me Ichor Cods,you must
,JO forthwith comply with such provisions or this permit shall x deemed mvokcd.
Z tiCONSTRUCTION LENDING AGENCY
[.r Ihereby affirm that then is a conswction lending agency for the perfurmanco of
gY,r7 me work for which this permit is limed(Sec.309'1,Civ.C.)
WQ Undoes Namc
04 z Under'sAdd..
U I certify that I have read this application and mine mat me be.information is
F COMCL I agree to comply with all city and county onlinuces and sure laws mlating In
0U building construction.and hereby amhorim mpmacnmtiver of this city to enter upon the
W shave-mcntionod property for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments.casts and expenses which may in any way ammo against Said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURg REGULATIONS.
_'49G1w10 Re-roofs
12 a`u mAppl mn1Le m
a of Roof
HAZARDOUS MATERIALS DISCLOSURE Typ
Will me applicant tar futum building meupmtstom or handle harardous maodal
as defined by the Cupertino Municipal Code.Chapmr 9.12.and the Health and Safety
oda,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Na
Will the applicant err future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Diarics7 -�
❑Yes
I have read the hawaMousmaterials uquimments under Chapmr6.95 of the Califon
ria H.INXs Safety Code,Sections 25505,25533 am1255N.1 undersand thuirthe Wilding
does not mnendy hes a wmm mat it is my respana liry o o ufy me occupant.(,he
�m vim n,whmlmu&" ,,�do�rw�iateancenncamBaamaram an Signature ofApplican[ Date
4r g� ow All roof coverings to be Class"B" or better
0 nor ser aut onrcd agcm Dam
' Community Development
10300 Torre Avenue
Cupertino CA 95014
i Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
/ uE a�0
OWNER' NAME: 4 - PHONE # p
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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 C
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO (�
� - FURNACE/AC 2/
#UPCITY OF
ERTINO PERMIT APPLICATION FORM
APN # i Date:
Building Address:
6
Owner's Name: Phone #:
uLA / " G - d o363 —
Contractor: Phone: License#:
k.4ICA C of f,)- 171;, 26 gP do;7/
Contact: Phone: Cupertino Business License#:
11711
Building Permit Into:.
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
"A.4 -. 4,eao/.1i a JKL 6' vim, 47-0
Residential ❑ Commercial ❑
For Residential Installations:
Attic ❑ ls` floor ❑ 2"d floor❑
dhere to min set back re uirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installa 'on Planning Approval Required ❑ X�T
Cost of P e t: Type of nc 'o Occupancyfo/�,
Strapped On Platform ❑ Bo ed ❑ Sq.Ft. Floor
New Location ❑ Replacement ❑
/Qty. if
A ab_le 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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