03100015 I ITY OF CUPERTINO , &'F"K�`^vil+'Mx= wcv
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION V..
IBu1LDING ADDRESS: CONDITIONED AIR PERMIT N903100015
573 T�TATERRQRP DR
OWNER'S NAME: 16413 GILMAN AVE FERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(408) 374-6311
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;00
LICENSEDCONTRACTOR'SDECLARATION Job Description
YI hereby affirmfthat I am licensed under nd loess of Chapter 9(commencing P
< with Section and
of Division Sof dm Busincxs end rufnsiom Codc.a ylicenm
n in full force and c n.
i = Licenu Cl2� L .aURN
lr
Dow
C
QQ ARCHITECTS ECLARATION
i 2 I undersand my plana shall he used a public records
is.
oG Licensed Profcuinnal
5 OWNER-BUILDER DECLARATION
<2 1 hereby office that I am exempt from the Comramfs License Law for the
e o o following,conn.(Section 703 1.5,Business and Pmfcssions Code:Any city or county
S$ which requires a Permit to construct,eller,improve,demolish,or repair any seucturc
.Zi prior In its issuance.also rmuimv the applicant for such permit to file a signed statement
< that he is licensed punuanuothe ProvitlmsOrftContrnemr'sLicense aw(Chapter 9 Sq. Ft. Floor Area Vfluatlon
2�� (commencing with Section 7000)of Division 3 of be Business and PropseemnsCash)or
15F Nat he 6 exempt therefrom and the basis for the alleged exemption.Any violation of 36617029 . 00
Section 7031.5 by any applicantfor a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan rive hundred dollars(5500).
❑I.as owner of the propeny,or my employee wish wages as their cele compensation,
will do the work and the almaure a.1 amended orolfered for safe(Sec.7044,Badness 301 — ROUGH � ction5
and Pinadmdans Code:The Conlaacmr's License 4w does not apply to an owner of
property who builds or improves thereon.and who does such work himselforthraugh his 303 — ROUGH M CHANT AL
own employees.provided that such improvements an not intended or offered forale.If. ,304 — ROUGH ELECTRICAL
however,she building or improvement is aald within one year of compindon,she owner-
builder .will have the burden of proving that M did not build or improve for purpos,of 505 - FINAL ELECTRICAL
ale.). 507 - FINAL PLUMBING
❑I, s owner of project
prOpirty,amc.71]4 .B siness andvely contracting wish:)The
eanuenon to
came La the es not (Sec.o on eeriness and Prowho bui Coda:)The s demand.
Li- SOH — FINAL MECHANICAL
cense law does not apply a an owner of progeny who andp or improve Norton.and
Aff 9A
who contracts for such proFcu with a conwcmrtq liccnad pursuit a de Contactots
Lesson,1.Law.
❑lam exempt under Sec. ,Bk PCfor dols moon
Owner Doe
WORKER'S COMPENSATION DECLARATION
1 Mrtby aRum under partially of perjury oro or the following declarations: -
I have end will maintain a Cenifiena of Convent to self-insure for Worker's Compen-
soinn.as provided for by Section 37W of Ne Lather Code,far the perfosmonm of the
work for which this permit is issmd.
have and will maintain Wmkefs Compensation htsmana,a required by Section
7W of she labor Code,for she performances of the work far which this permit is issued.
My Worker's Compensationn Insurance carrier and Policy number atm::
CarrieryZg+v54sil Ws'aaM Policy Na.:1 1D / Z'S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he complced If the permit Is froom hundred dollars(SI W)
or leas.)
1 certify that In the perfmmanec of NC work for which this Permit is issued.I short not
employ any person in any manner an as an bmomC subject to the Woftnr Compensation
Lawn of Celifomia.Dem
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions or the labor Codc,you must
�Q forthwith comply wish ouch provisions or this Permit shell he demand missed.
CONSTRUCTION LENDING AGENCY
1 herchy affirm dont thea is a convection lending agency probe Performance of
Y4>,t the work for which this permit Is issued(Sec.3097,Civ.C.)
S1 Q finder's Nam.
z Lenders Address
Q I certify that 1 have mad this application and soon that be above information is
Fcorrect,l agree to comply with all city and county oNin meas and tote lows palating m
�U building construction.and hereby aothomerepresentatives ofthis City toenter upon the
„C shove-non Toned property for inspection purpal
(We)again to ave,indemnify and keep handles the City of Cupertino against
ti r/) liabilities,judgments,costs and..penes which may in any my am..against aid City
J 7^n inconaecAm ofthegran' So permit. a
APPLICA ND S DWI 0 TH ALL ON-POINT Issued by: Dat
AP
C S.
s l°' Re-roofs
Signaua i fA,limmu Canlracmr Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant car future initial,occupant store of handle henrduus material
as de0ocd by the Come"..Municipal Code.Chapter 9.12,and the Health and Safety
ode.S.etias 2ssu(a). All roofs shall be inspected prior to an roofing material beim
❑Y No P P Y g g installed.
Willi
the applicant tar Tulare building mcupnnt use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it normsh to air ominana u donned by the Bay Aon Air Quality Management all new materials for inspection.
riot?
❑Yes u
1 have mad the amadous maler'als re9viaments underChoPnr 6.95 of the Califor.
nia Hwllhd iy Codo,Sc on 525533 25534.)uada=that ifthc building
I..not c rely h tea N it u my ort' i m odl'y the rccupent of NB
assn a CmmanafOCCUP Signature of Applicant Date
I�'"'l � All roof coverings to be Class "B"or better
Owner or avthorivcd agent Doo g
10/02/2003 IS: 22 5105303202 LEGALITIES INK PAGE 03
t .
forth Bay Permit Service
3988 Somerset Ave.
sota CITY OF CUPERTINO Castrovalley,CA 94546
FURNACE/AC
tUPEkTINO P ,RMIT APPLICATION FORM "� 3Z
S/ 0 5
[APN# 3/(_ 7Date:
�U/ Z- 0 3
uilding Address:
7573 LO ,1 �
Owner' Name: @ Phone #:
3 6 _
Contrac[ f Phone:
License
Contact: r Phone: Cupertino Business Li ense#:
¢rn�. _ Z-2—
Building 3
Permit Info:
Bld Elect Plumb Mech
Job Description: : ��' U _75 , o o o a+L(
Residential I Commercial
For Residential Installations:
Attic 1" floor 2nd floor
dhere to min set back re uirem nj
or Commercial Installations:
Replacement same weight ❑ . iAdditional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation Planning ADDr�'gal Required ❑
Cost'of Project: —f— Type of Construction: Occupancy group:
02 • o0
Strapped ❑ On Platforin ❑ Bonded ❑ Sq.Ft. Floor Areae
New Location C3Re lace nent ❑
Qty. if ;
A licable Fee 'D Fee Description Fee Group
BENERGY EnRFma
BUILDING'
BRE�IF[JRN _ Ref Furnace MECHANICAL
BREMACO A/ 10,000 cfm MECHANICAL
BREMAIIZH A/ = 1Q 000 cfm MECHANICAL
BREMREC) P Ritch &'Outlets ELECTRICAL
Se Res BUILDING
EPERMITFEE Elt Issuance ELECTRICAL
PERVITTFE Met Issuance MECHANICAL
PPERMITFEE i _ Plumbing Permit Issue PLUMBING
BPERMFEE Bld Permit Fees. BUILDING
BPLANCHK, Plan Check Fee BUELDING
BUSLIC `*` Business License . I BUILDING
S-