04030013 CITY OF CUPERTINO .,w:.as:;arw »rvr
BUILDING DIVISION PERMIT CONRACTURTNbRMATION, _
BUILDINGADDRFSS: A PERFECT CLIMATE PERMrrNO04030013
TT.yNX
Wy
W NER'S NAME: PERMIT ISSUE DATE
HOFFMAN MABEL
ONE: SANITARY Nis. CONTROL NO.
(408) 861-9545
ARCHITECDENGINEFR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSEDCONTRACTOR'SDECLARATION Job Description
I hereby )of Nm I em f the
under Provisions m Chapter 9(commencing p
with Section]IXp)ofDiviaion3of Nc Btuin EProfessou Code,and my tic t Is
ny(9/n REPLACE DUCT
Z_ manse CM�s "CCWbbeyoIMpp-eeDD"rr j
1 HI CI-SDECLAR 1'N `S
�i I understand sy pl a a1Wl W used u public mcards �e
3 7
i tad� Licensed Professional �f
OWNER-BUILDER DECLARATION �/J
HE I hereby,(Sec on 11. exempt from ted Contractor's Co :Any c Lew for the glC,
HE O O following meson.(Semon 703 1.5.Business and are, lou demolish,or Any city or county
w$to which requires•e.also ac cnnswa,eltea improv, ermittor repair ed statement
FZy pdmoiurensedp pursuant
nttacqo We tWvotionant for suchPermitI-Jecoo rite Law(Chapter
NoNatWisdcenxd pumtenTME)Provisionsn othe fteBusines andcenselsw(Geptar9 Sq. Ft. Floor Area Valuation
S (cm he is exg with Section]000)of Division r the al aged exemption.
prion.nd Any vi Ceuta)or
R.. Nu Section
B exempt Iherefmm and Ne aura for bj alleged s,semsed to Any violation of
not mo 707 L5 by My applicant for•permit subjects Ne applicMt o a civil penally of �l8T74hftAcr0 0 Occupancy 1T e
not mom Nen raw hundred dollen(5500). Q y +'Q
❑1,u owner of Me property,m my employee$wIN wegu a Nei...le compeaation,
will do Newark,and Neswcwn 13 not intended or offered fm Axle(Sec.70M,Baines
end Prof esiots Code:The Conditioner's Liam Law data not apply to M owner of Required Inspections
p ropeny who builds ar im proves Woman,$nd wha does such wok himself or through his
own employees,provided that such Imprownents art not Intended areffaed for sale.If.
however,Ne building or improvement is sold within arc year of completion,the owner
Wilder will have the Widen of moving Nal he did not build or Improv for pursers,of
Axle.).
❑1.as owner of Ne property,am ex tualvely contracting with licoaed Mmractnn to
construct the pmjut(Sec.]Oda.Baines and Pmfesiau Caonu
Cale:)The Cacofs Lr-
come law docs nor apply to an owner of property who Wilds or improves Nemon,tad
who conaecta for such pmjeeu with a commolor(s)licensed putaant to the Contractor's
License law.
❑I am exempt undo Sec. ,B k P C far this mann
tuner Data
WORKER'S COMPENSATION DECLARATION
I�t 1 hereby a1Rrm under penalty of perjury one of Ne following dalaratloa:
g I now and will maintain a Certificate of Cogent to se161aurt for Warker's Compeer.
Milan,As provided for by Section 3700 of the labor Code,for Ne performance of the
work for which this permit Is issued.
❑I haw and will maintain Worker's Compeuatian Imes area,As acquired by Sectian
3]00 of Me labor Cade,for the performance of We weak for which this Permit is issued.
MyW aa c Wunnce certicr arJ�d Policy num
rytr. �1 F[A0i✓(. 'icYNo.: 7`9/ 9
/VC TIFIR—E G'IE OF EUFJEKEMpyYON FROM WORKERS'
COMPENSATIO INSURANCE
(This=lion need not W completed trim permil is rerun,Wndoddallars(5100)
or less.)
1 certify Net In Ne performence of the work far which this Permit is issued.I shell not
employ any no.in My mantra As to WMmt subject to the Walken'Campeaetion
law$of California.Data
Applicant
NOTICE TO APPLICANT:If.aMr making this Certificate of Exemption,you Mould
Wcume subject to the Workees Compensation pmvislom of Ne Labor Code,you must
.J O real comply with such pmvisioa at this permiuhall W deemed revoked.
zZ7 CONSTRUCTION LENDING AGENCY t
Fr ImachyslOrm Net Nem is a construction lending agency for tedl cafurmma of
eL Ne work for which this pencil is issued(Sec.3097.Civ.C.)
ALenders Name
z Lender's Addles
U Q I certify that 1 have read Nis application amt sesta that the aW are WformNan is '
L,,P correct.I Agra to comply with all city And county oNlnancta and state laws elating to
0 U Wilding construction.Md hereby authodn rcprucnutim of this city to trot upon We
[t] above-mentioned propeny for inspection purposes
FC+' (Wo)agree to an.indemnify And keep harmlca the City of Cuperdno against
t;n Iiabiliuebjudgmenu.costs no
eapensea which may in My wayece.against said City
U Z in cauequenct of the granting of Nis pe t
^ APPLICANT U ERSTANO ND L COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REG ATI(3Pi3:
3 Re-roofs
tart of Applian fContracmr Data
HAZARDOUS MATERIALS DISCL Type of Roof
Will Ne applieant ar fume Wilding occuPMt store or le ha�eus material
defined by the Cupertino Munici Chapter 9.11.M the HcaIN and Safety
d,.Scotian ns32la)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
No
Will Ne 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 hamadous air comuminum u&rLncd by the Bay Area Air Quality Management all new materials for inspection.
District'?
❑Yes unU
thaw mad Ne haallommaoriaheLd25534.
ndcrChepmrG95ofthtCalifor-
niaHcaith&SafctyCak,Secuou 25505.253l uderstand thulllhc Wiling
data not eurreml saw a tenant Nat h is mty 1P floury the a cepsnt of Nemm nowh aAtbrmet IMuNmanofOccupary. ,,IgnatureofApplicant Date
wncronutherisAa cot 7 All roof coverings to be Class"B"or better
Community Development
' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRES eI D3� l.(J�S+j ww PERMIT #
OWNER'S NAME�lO l PHONE # AV?f)
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
�i Linoleum/ Wood
Glazing
Heating rna/Pi
litmfallo-n
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
Owner/Contractor Signature Date
CITY OF CUPERTINO
C , FFURNACE/ACRNACE�AC 03 o �A��
` " OF
UPERTINO PERMIT APPLICATION FORM
APN # D Date:
3-S-? z � 3-z-o
Building Address:
1 a 32. y
n�sUNam i1��✓1 P �� -► - 353"
Contractor: Phone: License #:
��T GtlrnvtA-e— AO�- g(pI - �IS� IS -72 1
C ntact:. Phon : Cupertino Business License #:
A,I - . caro' rez- Stvl-�Sy S
Building Permit Info:
Bldg�L7 Elect ❑ Plumb ❑ Mech
ob Description:..
elelCe �Y11 �ucT
Residential 0 Commercial ❑
For entialtallations:
Attic 1"floor 2 a 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 ❑ rL
C st of Project: Type of Construction: cu y 9Fo
O O ; 0 J A v fA- G.
Strapped ❑ On Platform ❑ Bonded ❑ Sq. ea:
New Location ❑ Replacement ❑
t if
ble 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
Vjj MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
U
Bqsiiiess License BUJLDING
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