05040188 CITY OF CUPERTINO ""'3 "rzra�+�,y�+�",�r y'".r ' .a:�w}�� ",pK�,�r
BUILDING DIVISION PERT �GONTR"ACTOR IktAFOA\1YlAT
aask£lF�,4mF+w"*>&b� k
BUILDING ADDRESS: SCHAUMANN AIR CONDITIONING ,PERMIrN 05040188
OWNER'S NAM : - PERMIT ISSUE DATE
NE: SANTfARY OL NO.
RCHITECDPNGINEER: BUILDING PERMIT INFO
BLDG EIER PLUMB MECH
0 0 0 0
�0po LICENSED CONTRACTOR'S DECLARATION lob Description
rd 1 hereby affirm Net 1 Am licensed under premAi m of Chapter 9(commencing
n�1
With fuSection 70111I)ofDivlelon3af NC Business ad Pmfcsaiom Codo,ad my license is �'P �t O ��
in full forte and Bce ,pYV//'®
vx�ZV
LlcenseCw r • - Le.N REPLACE FURNACE & A/C / [
E Dam AflCHll heus3 DEC ATOM
I uMertunJ my peas mull M rS a public ATf0N
3
i etd�
Licensed Professional
OatNEm exempt
from
DECLARATION
iI 1 thereby 4lfinm that I em ucmpt from Ne Commoners License Law for the k'
m O following moan.(Section NO L5,Business and Profweu Code:Any city or county I
$1 which requires a permit to construct.alcor,Improve.demolish,or repair any strocturc ✓
_Z12 prior to its lavance,4150 requires the applicant for Such Permit to file A signed statement
mm< that he is licensed pmsuent in to previsions of the Contractor's Leenw law(Chapter 9 Sq.Ft.Floor Area Valuer On
F� (commencing with Suction 7000)of Division 3 of She Business and Professions Coast)or
that he is exempt therefrom and the basis its the alleged exemption.My violation of
Secdon 7031.5 by arty appliant fora permit Subjects the applicant in a civil penalty of
not ream an.fin handmd dollars(5500). 3 J*Sr0 0 Occupancy Type
I,uownv of die propeny,ormy emplaym with wgeSUNah50lecempenatian,
will do thework,andthe Structure is notintended araRered forsala(Sax.706/,Business Required Inspections
and Profealoo Code:Ilse Communes License Law does net apply to an owner of q P
property who bulldsorimprowa Narcan.and who doessuchwmkhimselfor through MS
own employees,provided that ueh Improvements Am not Intended arortemd fireside.if,
however,the building or Improvement IS Sold within am year of completion,the owner.
Wilder will have tie Wrden of proving that he did not build or Improve for purpose of
sale.).
❑1,AS swam of She property,am exclusively cmuuning with licensed emwctora to
construct the project(Sec.7044.Business and Profrssimu Cade)The Contra mra U.
cease Law does not apply to an owner of property who With,or Improves Memon.ad
who comencu for such project,with aconusemr(s)liuved punwm to the Contractors
License Law.
❑I am exempt under See. �.0&P C for this moon -
Owner Dam
WORKER'S COMPENSATION DECLARATION -
1 Mmby aRam under penalty of perjury um of the following declaatiau:
1 hamend will maintain a CCNfiam ofComent to mlf-iuum for Workers Compere
ution,u provided fm by Section 3700 of the labor Cade.fm the performoa of the
.it for which this permit I4 issued.
❑1 have and will mainuin Worker's Compensation Insurance,As required by Section
3700 of that labor Code,for the p rformame of the work for which this permit is issued.
My Workers Compensation Issuance artier and Policy number am: -
Carder: 770�eze /L Policy No.:741 f5/ qGQ�
CERTIFICATEOFF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis sectim mW net M completed fifth,permit Is forom hundred daRass(SIM)
or lea)
I unify that In to performance of the work for which this permit is Issued,l Nall not
employ Any person in any meaner an As m became subject to the Workers Compensation
Lew.of California One
Applicant
NOTICE TO APPLICANT:If,after making this Cer iricem of Exemption,you Should
become Subject m Ne Worker's Compensation prevision.of She UMr Cade,you mum
.JQ forthwith comply with such Provldoas or this permit shall be deemed mvoked. '
'Z CONSTRUCTION LENDING AGENCY
F 4 I hareby affirm that deo lea mccusucuo,binding agency for She pufmarmoo of
C> the work for whim this permit is iamd(Sac.3091,Civ.C.) -
I:1 QZanders Name
0. Z LandersAddress
U Q I unify that I have mad this application and sum that the above information is
IL ;•'! cormcL I agme to comply with all city ad county eminences and sate law.miming In
Q trJ' building construction.and hereby auNmlm representatives of this city m cow upon the
Ii7 ebovcmentioned property far Inspection purposes.
gyt (We)ague to ave,indemnify and keep harden She City of Cupertino against
n,S y Ilabilida,)udgmona,cents And expenses which may In my way acemc against said City
in
C.)rZ. APPLIC NT UNDERSTANDS ANDence of the Inviting of WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERECULAi
Re-roofs
n'nuure of AppliandConuxemr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fu t m building mcupanl nom or handle harsmous materiel
a defined by the Cuportme Municipal Code.Chapter 9.12.and the Health and Safety
ode.Secuon 25532(e)? All roofs shall be inspected prior to an roofing material being Installed.
pyo ❑Na./ P P Y 8 g
Will the applasal or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haeamnu ai,cmamiumts ae defined by the Bay Ame Air Quality Mwgcmern all new materials for inspection.
urict7
❑Yes ❑No
1 have mm the huamms materials requirements under Chapter 6.95 of the Califor.
nia Health sic SafetyCoda.Sections 25505,25533 and 25534,1 undersand that if the Wilding
des not currently ban a wham,Net It is my responsibility to amity the omupmt m dor
myvirtmc �whiichmust et pd tomaenaor.couric maraap.n / Signature of Applicant Date
Gf/ Z SCJ
owmermallimvcd.gem Daa All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCOF Fax(408)777-3333
�UPEt�TINO
Building De artment
JOB ADDRESS: PERMIT#
Z , O SO ki O /S-S�-
OWNER'S NAME: JPHONE # Z59 • `JV-2/
GENERAL CONTRACTOR I FAX# 6-
I am not using any subcontractors,,,,/ A), `el 29. 6 S
Signature Date
Please check applicable subcontractors and complete the followinginformation -
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
s
Owner/Contractor Signature Date
CITY OF CUPERTINO
0 FURNACE /AC opq ()/&
CUPEI,TINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
/ Z /G <1
Owner's Name: Phone#:
ZS - 282-
Contractor: License#:
-7 70
Contact: Phone#:
/-A/V /-,Ten - O 13 3
Applicant/Congactor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: Commercial:
Sq.Ft.Floor Area: $/Sq.FL:
/ 7�
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Qty, if
A licable Fee ID Fee Description Fee Group
BENERGY Ener •BUII,IDNG .
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAUMAN A/C Units <= 10,000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch&Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMIIFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
q 75 ° `/