03090250 CITY OF CUPERTINO
BUILDING DIVISION PERMIT dCQNTRACTORfINF0�MATION `
a BUILDING ADDRESS: CONDITIONED AIR PERMIT NO.03090250
,01022 17nc;.q A17
OWNER'S NAME: 164B GILMAN AVE PERMIT ISSUE DATE
STATMAN NAVAH
ONE: (408) 374-6311 SANITARY NO. CONTROL NO.
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
0 0 0 0
,00 LICENSED CONTRACT'OR'S DECLARATION Job D05CTIPhOn
i u C I hereby affirm that I am licensed under provisions etch Icr 9(commencing
w with Sced.m70Kpcf Di ,dmm3of NCBu' ,send Pmf edo c,cad my'ch.is
in fail force and e t . NALE®
iNz Lice 'LU REPLACE FURNACE �',V
g Data U cumracm, _
iaa IunderstandmyplanR hH1T�CT5DE^uuARArend FEB 1.7 2004
1yU
Cm Licensed Professional
OWNS fr DECLARATION
<f 1 hereby air.that 1 eR.
m exempt exempt from the Contractor's License Law far the BUILDING
p o following rcaaon.(Section 7031.5,Business and Professions Code:Any city or .Only
$ which requires a permit to construct,alar,improve,demolish,or repair any structure
.Iapnono its issuance,also requires the applicant for such permit m File a signed statement ,i nni
That he is licensed pumuanl to the mvisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
j $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt dominant and the basis for the alleged exemption.Any violation of 34250017 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to acivil penalty of APN Number Occupancy Type
not more than fiinhunarcaaelta.(SSW). P Y YP
I,us owner of the property,or my employees with wages as their sole compensation,
will do lie work,and the structure is not intended oroFrbmd foraale(Sec.7044,Business 3ul RUUUH
—
and Professions Code:The Contractor's License Law does not apply in an owner of 303 - ROUGH M HANI AL ns
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended ormlicred forsale.IL 304 — ROUGH ELECTRICAL
however,One building or improvement is said within one year of completion,the owner-
_ builder will have the burden of proving Nal he did not build orimp.vefor purpose of 505 - FINAL ELECTRICAL
'°I`')' 507 - FINAL PLUMBING
❑sae owner of the property,am exclusively contacting with licensed contactors i.
cense Lx the es not(Sec.o an wner of and Profusions Code:)The Convenor's Li 508 — FINAL MECHANICAL
cense Law dose not apply to an owner of property who sed p or improves thereon,and,
who contracts for such projects with a conuanar(a)licensed pursuant to the Contractor's
Law.
0 1 rum 1 am exempt under Sec. ,B&P C far his rcuon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby a1Tum under penalty of perjury arc of the fnilawing declmmimer:
L have and will maintain a Certificate of Consent to self-insum for Workers Compen.
nation,m provided for by Section 3700 of the Inbar Code,for the performance of the
work far which this permit is issued.
have and will maintain Worker's Compensation Insurance,as rcquiud by Section
00 of the labor Code,for the performance of the work forwhich this permit is Issued.
My Worker's�C�nmp�en�gagy'nn I/n�s�ur;Z artier and Policy number am:
Cartier, —'^^M sU/YL�I• Policy No.; �_
CERTIFICATE OF EXEMPTION FRO 0 KER
COMPENSATION INSURANCE
This section need not ho completed if the Permit is forma hundred dollars($1 00)
or less.)
I certify that in the performance of the work for which this permit Is issued.I shall not
employ any rumen in any mandarin,u to become subject o the Workers'Compensedon
Lam of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this catiacaa of Exemption,you should
become subject to the Worker'a Compensation provisions of the Labor Codc,you must
Oforthwith comply with such provisions or this Permit shall he deemed revoked.
�► CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
Ya> the work for which this permit is issued(Sec.3097,Civ.C.)
j]Q Under's Name
7 z I<nJcr1 Address
0 I certify Net I have reed this application and stale that the above information is
H correct.1 agree to comply with all city and county ordinances and state laws relating to
�U building constunion,and hereby authmiu representatives of this city to enter upon the
„LU ,hove-mentioned pruriently for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
ti h liabilities,ju env.costs and ex ca which may at any way.enema again;...id City
;)z in coney ofd r n t perms.
A '1 TA p WITH ALL p'ON-e01NT Issued by: Date
sou s. 9/
e3 Re-roofs
Signature of Applicam/Comracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant care or handle haardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode,Section 25532(a)?
Yca 0s?� All roofs shall be inspected prior to any roofing material being installed.
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 hazardous air conmornm nts us defined by the Bay Area Air Quality Management all new materials for inspection.
istrict?
❑Yes N
I have mad the havamnus materials requirements under Chapter6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 ond25534.I understand that if the building
does not curtently a tenant that il' 'y responstyyl..)m notify the Oce I of are
rcyviumcnts w ' est r'suanccof L'crurcpeaf Ocptyaa y� Signature of Applicant Date
Owner.authori,,,d agcnl y m� All roof coverings to be Class "B" or better
J
Q� CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# q 0 Date: G 3� 03
Building Address: /Owner's Name Phone#:
!"You.`,
Co torr� p.. Phone: License#:
ins ;19/ -ZZZzv 1�LkS/(� Z
Contact: Phone: Cupertino Business License#:
�Cl�m�i v C5�,Z_� 2 2-3 3
Building Permit Info:
Bldg N, Elect ❑ Plumb ❑ Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1"floor El 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Constructi Occupancy gr up:
/00 / . Uail
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacement T,
Qty, if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
1 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
EPERMITFEE Elec Permit Issuance ELECTRICAL
/ MPERMI TFEE Mech Permit Issuance MECHANICAL
1 PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING