04020001 CITY OF CUPERTINOBUILDING DIVISION PERMIT CONTRACTORINFORMTION
BUILDING ADDRESS: FALCONE PLUMBING & HEATING PlL tN004020001
OWNER'S NAME: PERMIT ISSUE DATE
MONICA PROTECTOR
ONE: SANITARY NO. CONTROL NO..
(408) 293-5676
RCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT - PLUMB MECH
0 0 0 0
LOO LICENSED CONTRACTOR'SDECLARATION Job Description
Z C 1 hercby affirm Nro
al 1 am licensed under pvisions of Chapter 9(commnc
eing -
<U with Section] BofDivvmc.SalNCBusinusandProfessionsCodc,andmybeen.is
jF o LDidcNme, Z- LCiUcn.Up
aREPLACE FURNACE FINALE=LE=
g [of F.
cLaGI
ARCHITECTS DECL ATI N _. FEB 0 5 2004
�y qa understand my plans shell be used as public remNs
�6u
;may Licensed Professional '
Oat I am
DECLARATION BUILDING
E e f I naso ,(Sero(Section nt 1 1. cBusin from the CosionsC s License Law for the
i p 0 follwhich requires a Pitto construct,
8usitar.simprove.
ve.d ri oli Code:Any city as county
<m which requires issuance,also re quires the elle,improve,demolish,or repair any structure
yZN triton itsensed pursuant
requires thevisio tonsof for such the Contractor's
ontra toe's imnsele a Law(ned Chapter
£ < that he(mommealiccdscdpurstion7 h)of Division3oftheB sinessandProflaw(Chopmr9 Sq.Ft. Floor Area Valuation
45§ (cat he
xem with hereiromand7 the
Divisions of theeged exemption.
Any vi Cock)or
y�$ Itis(he is exempt therefrom and Ne basis for the alleged exemption.Any viplation o!
Section 7031.5 by any applicant for a mmil subjects the applicant to a civil penalty of 316ITNI'td3flier0 0 Occupancy Type
not more than five hundred dollars($500). P Y YP
❑1,As owner of the pmpeny,or my employees with wages as their ale mmpensalion,
will do the work,..it the structure
is not intended or offered for sale(Sec.7046.Business Required Inspections
and Profusions Code:.TW Conlnctor's License Law does not apply to an owner of q
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If, --
however,Ne building or improvement is sold within one year of completion,one owner- ,
builder will have be burden of proving that he did nal Wild or improve for purpose of
sale J.
❑1.as be,of Ne property,am exclusively contracting with licensed convectors to -
connram the project(Sec.7044.Business end Professions Cade:)The Contmemla Li
cense law docs not apply to an owner of property who Wilds or improve thereon,and
who contracts for such projects with a contracto bd licensed pursuant to the Contractor's
License law.
❑I am exempt under Sec. .B&P C for this rcasun
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby TO.under penalty of pedury one pf the following deelamlions: ,
1 have and will modal.a Cmdf..to of Carcass.$0f.insum for Wmker'sComped-
ion,az provided for by Section 37M of the labor Code,for the performance of the .
weak for which this permil is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Coca.fm to performance of Ne work for which mix permit B issued ,..
My WorkeriC7mpensetion lnsmtt
Insurance carrier nd Po' number au:
r. �J -Poli PO�
.927- ,/
ERimuArE N FROM WORKERS'
COMPENSATION INSURANCE '
,
Gress section decd not be completed if rW permit is foronc hundred dollars(gl(gB
or In.)
1 certify that in the pe rfmmance of the work for which this permit is issued,1 shell nut
employ any person in any manner so as in become subjecup the Worker[Compensation
Laws of California.Date ..
Applicant
NOTICE TO APPLICANT:IL after making this Ccniftcne of Exemption,you should
become subject to the Worker's Compensation provisions of the lahor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z ti CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that there is a construction lending agency lot he performance of
Cli > the work for which this permit is issued(Sec.3097,Civ.G
LQ A Lendcr'a Name
] z Lender's Address
U Q 1 cenify that 1 have read this application and stale that the above information is
ty F morcel.I agree to comply with all city and county ordinances and state laws relating to
0U building co ' ion,and hereby emM1in;-pre"moo.-A of doa city to enter upon the
;' snore noon- Ity,rormapeedmi purpoads.
(Wc)egme to savc,' dcm yard keep harmlcv the City of Cupcnino against
w VI lim lites,judgm .cos and tenses wM1ich may in any way ucrue against said City /
inconuqucncc c6r tin (This permit.
APPLICANT E T OS ND WILL COMPLY WITH ALL NONPOINT Issued by: Date
50 RCERE
Re-roofs
Stg of ApplicaMContranor Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumm building aacupont slorc or handle harardous material
u defined by the Cupertino Municipal,Code.Chapter 9.12,and the Health and Safety
AN6EOdc. e25su(a)7EYs „ All roofs shall be inspected prior to any roofing material being
Will applicant or fumrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Of ha'samnus air main.n ts az dcf,ned by the Bay Arca Air Quality Management all new materials for inspection.
strict?❑Yes o
Mly
mous"Ide Is requirements under Chapter 6.95 of the Califon. .,
ria HSecdpes 255(15.25533 enJ25536.1unticrsmnd Not iflM Willing
Jars means.Net it is my mspmisim a nodlIthe acupdnt ofdiemeatmet Poor Onissuanccoface camof capad"y. Signature of Applicant Datee L o All roof coverings to be Class t'B" or better
CITY OF CUPERTINO
FURNACE/AC
CUPEI�TINO PERMIT APPLICATION FORM /
APN # 3 // [�� p Date: Z D
Building Address: / a
622- 012 ,
Owner's Name: Phone
G
Contractor: Phone: License#:
76 4rO
Contact:�A pK� hone: _ Cupertino Business License#:
vC L9 !0 76
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mec
Job escrip ion: 11� ,,_ /<n
Li2ac _C
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor �'2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
eplacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project:41 6 !�-v cl-�2 Type of Construction: Occupancy o
Strapped ❑ On Platform L1 .—Bonded ElSq.Ft. Floor Area:
New Location ElRe lacemeD
Qty. if
A 1' 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
7 n BUSLIC Business License BUILDING
72 , 37