03110119 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT COIVTRACTOIt INFORMATION.''
BUILDING ADDRESS: PERMIT Nrb 3 110 11 9
OWNER'S NAME: PERMIT ISSUE DATE
JENO RONALD W AND 11/20/2003
NE:
SANITARY NO, CONTROL NO,
ARCHITECDENGINEER: BUILDING PERMIT INFO
BGSELO PLU=MB ME=CH
;Op LICENSED CONTRACTOR'S DECLARATION
I U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Descrl[I(10;
with Sec ionBnf DivisionJof the Ousjpt5gand Profcssinns Code,end mylieense is (rte NA1.ED
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— FUNACE REPLACEMENT
Z License lass Llc.N
O Dow Com for -
rJ` ARC TECTS D RATIONS JA M 62004
u�((yy33 underatanJ my plans shall he used as public records
ya
5e.1— Licensed Professional Y��
g OWNER-BUILDER DECLARATION BUILDING,
<f 1 hereby wittrm that I am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any City or county
5 which requires a Permit to construct,alter,improve,icmolkeh,or repair any structure 81993
prior to its issuance.also requires the applicant forsuch permit to RIC a signed statement
FFZInthat he is licensed pursuammthe previsions ofthe Contractor's License Law(Chapter 9 Sq. F[.Floor Area Valuation
e+t$ (commencing with Section 7RBB)of Division J of the Business and Professions Conic)or
s.3 that he is exempt therefrom and he basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 3W*00 aiO0 Occupancy Type
net marc Nan five hundred dollars($500).
❑1,a owner of the property,or my employees with wages es their sole compensation,
will do the wart,and the stmcwm is not intended or offered for solo(Sec.7(144,Business Required Inspections
and Professions Code:The Contractor's Licemve Law does not apply to an owner of q p
property who builds or imptovu thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for role.If,
however.Ne building or improvement is sold within one year of completion.Ne owner-
builder will have Be burden of proving that he did not build or improve for purpose of
sale.).
ED I,as owner of the property,am exclusively contracting with licensed contractors in
construct the project(Sec.7044,Business and profession Code:)The Convector's Li-
cents law does not apply to an owner of property who builds or improves themon,and
who contacts for such projects with a conuactoos)licensed pursuant to dm Convectors
License Law.
❑1 am exempt under Sec. .0 At P C for this Mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby arrive under penalty of perjury ow of the following declarations:
I have and will maintain a Certificate of Consent o self-insure for Worker's Compcn.
7371M
ion,as provided for by Section 37M of the Lebon Code,for the pelfmmaned of the
rk for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of rhe Labor Cade,for the performance of the work far which this Permit is issued.
Worker's Cnm nsaIion lnsumonewcomer and Policy number art: �]
V,r. t^/'hth- ey No.:
N
C RTIFICATE )F EXENUMON FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the Permit is foronc hundred dollars SI=D)
it,Ices.)
I certify that in the performance of the work for which this Permit is issued,l shall not
employ any person in any manner so az to become subject to the Worker(Compensation _
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Conifcate of Exemption,you should
became subject to the Worker's Com pcnotation previsions of the Labor Code,you must
.,,Z forthwith comply with such provisions or this permitshall he deemed invoked.
ti O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
Md> the work for which this permit is issued(See.3097,CO.C.)
QLender's Name
z Lcnder's Address
U I certify that 1 have mad Nis application and sera that the above informatiun is
L4 f-r correct.1 agree to comply with all city and county ordinances and state laws writing to
0U building construction.and hereby authorise mprcecmativen of this city to enter upon the
W above-mentioned property for inspection purposes.
gy (We)agree to save,indemnify and keep bermloss the City of Cupertino against
o-F.t to liabilities judgments.cents and expenses which may in any way same against said City
U Z in consequence of the granting of this permit.
APPL NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OU REGU TIO S.
Re-roofs
ore of Applican C mramor Dam
ARDOUS MATE IALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haardous martial
az defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ode,Section25532(a)? ((��a All roofs shall be inspected prior to any roofing material being installed.
❑Yes I mNu
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 havardnua air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
onnel?
❑Ycs Nu
I have read the hmaNnus materials requirements under Chapter 6.95 of the Califon
.in Health lk Safety Code,Secdom25505,25533 and 25534.1 understand that if be building
dos of cunenif have a tenant,that it a my responsibility m notify the Occupant of the
re env which must mem wissuanccofaCcrtificatgof ea ane. Signature of Applicant Date
ser or aumarr agent [// ate All roof coverings to be Class "B"or better
CITY OF CUPERTINO
FLJRNACE/AC o 3 1 r
CUPEkT1NO PERMIT APPLICATION FORM
APN # Date:
t - Zo -o�j
Building A dre s:
Voss ve _
Owner's ame: Phone #:
I e J4 3 y-� V-) 0 353 - 14 "60
Contractor: Phone: License#:
m� _ '4cl!�-1 (ea -C
Co tact: Phone: Cupertino Business License#:
( g— cr -
Building Pe it Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential A Uommercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2id floor❑
Adhere to min•set back r�-, uirement❑
For Commercial Installations:
Replacement same weight Additional weight (structural calcs) ❑
Structural Calculafns required for new installation ❑
New installation/Planning Approval Required ❑ Gr—'-1
09
Cost of Proje Type of Constructi Occupancy grc
jL-
Strapped ❑ O orm ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
AppliCAS, 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
BUSLICBusiness License BUILDING