03090053 ? CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION
• BUILDINGADDRESS: PERMITNO
OWNER'S NAME; KIDISON AV PERMrf LSEUE DATE
]NE: SANITARY NO. CONTROL NO.
ARCHITECTfENGINEER: BUILDING'PERMIT INFO
BLDG ELECT PLUMB MECH
!Op LICENSED CONTRACTOR'S DECLARATION lob DescrlptiamE a1 ��®
F 1 hereby affirm thit,1 am licensed under provisions of Chapter 9(commencing .NAL
with Section 7q%)"f Division 3of dim Business and Pmfcssium Cade.and my license is
in"°`�qC/n°"�Plh.11
StOr4n2 REPLACE FURNACE & ADD A/C
LicawfASs �, OCT 0 8 2003
,moo DaContractor
Com-`Tfac�s CONTRACTOR: SAN JOSE AIR
E� 1 unarsanPuhlic ran ds
''� Licensed Pnslcssinnal
ing uLDING
t 3 OWNER-BUILDER DECLARATION _
I 1 hereby affirm that 1 em exempt form the Contractor's License Law for the
00 following mason.(Section 7091.5,Business and Pmfcssinns Code:Any city or county
$ which requires a Permit hr cnmtruct,alcor,improve,demolish,or repair any structure
prior to its Issuance.also requires the applicant for such Permit to Glc a signed awcomm
'mema that he is licensed pursuunuothe provisions ofthe Commcmr'sLicenseLaw(Chapter 9 Sq.Ft. Floor Area Valuat' 390'
(commencing with Section 70M)of Division 3 of at Business and Professions Cade)or
,r, $ that M is exempt ftmfmm and de basis for the alleged exemption.Any violation of
Section 70316 by any applicant for a permit subjects the applicant to a civil penalty of 3MNJ N"gr00 Occupancy Type
not more than row hundred dollars($5110).
Q 1,as owner of the property,m my employees with wages as their wit compensation,
will do the work.and dcarietum O not mantled or offered for sale(Sec.7061.Business Re ulrc d Inspections
and Professions Code:The Contractor's Liadata ow Law danot apply to an Owner of 3 01 - ROUGH PLUMBING
property who builds or improves them..,end who doa,mch work himself or through his
own employe.,provided that such improwmena we not Intended or offered for sale.If. 303 — ROUGH MECHANICAL
however,the building or impovement is roto within one year of Completion,the owner.
build,,will have the ban&.of moving that M did not wild or improve for p.rusee or 304 — ROUGH ELECTRICAL
ask')' 501 - FINAL ELECTRICAL ENERGY
01,as owner of the property,am exclusively contracting with licensed contractors to 502 - FINAL PLUMBING ENERGY
construct the project(Sec.7044,Business and Professors Code;)The Contractor's Li
cense law dons not apply to an owner of Property who wilds or improves dcreon.and, 503 — FINAL MECHANICAL ENERGY
who contracts for such pmjecu wit a contrwmr(O licensed pursuant to the Contractoh
License Law. 505 - FINAL ELECTRICAL
❑l am exempt under Sec. .B&PC for this mason 507 - FINAL PLUMBING
Owner Dam 508 - FINAL MECHANICAL
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 bare and will mai main a Certificate of Consent o sel6insute for Workce,Compere
.tion,as provided for by Section 3700 of the laver Code.(a,the performance of de
work for which this permit is issued.
Fl 1 have and will maintain Worker's Compensation Insurance,as required by Section
3]00 of do labor Code.for the performance of the work for which this permit is issued.
My1Worker's Compensation Insurance Cartier and Policy number am: ��.�(���
Caber'. �'LaNd') Palley No.: k O—Ys-
CERTIFICATEOFEXEMP'fIONF WORKERS'
COMPENSATION INSURANCE
mossectinn need not hecomplemd if the fermis is for one hundmd d"Ilan(SIW)
car Iwd
1 certify tat in the Performance of the work for which fix permit is issued,1 shall out
employ any person in any manner was in become subjeeuo fie Workeri Compensation
laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this CC.ificate of EXOMPliOn.you should
become subject to the Worker's Compensation pmvanons of the labor Code,you must
.,O forthwith comply with such provisions or this Fermi,shall he deemed revoked.
zCONSTRUCTION LENDING AGENCY
Fy
+ I hereby aRrm that there is a consuuctint lending agency for the kofurmainc of
fk 7 to work for which this pmmit Is issued(Sea 3(197.Civ.C.)
l61 Q Lmder's Name
Lender's Address
U 0 1 cenify that I have read this application and was fiat the nave information is
0 Coma uildin 1 agree ctcomply with all city and county ordinances and sole la rte relating e
OU abownge0jornal construction,and hereby acdonl Rmpresenallves of dlf city mCOmrupon to
r W shove (We) ncd pro porty,save for imnify a proposes. qqq
(•-' (We)agree m saw,indemnify and kap harmless 0e City a/Cupcnino against /—
h Iiabilides,judgmesns,costs and expenses which may in any way accuse against said City
fJ7 in Consequence of the granting of this permit.
ram APP (CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: D a
SO E E ATIONS.
Re-roofs
Signature. enUCo rar re
HAZAoATERIALS DISCLOSUR Type of Roof
Will plicate of future building Occupant store or handle havarduus mattriai
y dm Cupertino Mum al Code.Chapter 9.I2,and[be Health and Safety
Coot,Section 25532.)7 Yes Nr All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or deviaa which If a roof is installed without first obtaining an inspection,I agree to remove
tit ho'.rdnus air conamina ns As defined by the Bay Area Air Quality Management all new materials for inspection.
Iwict?
❑Yes Nu
...
I havemad de hiciandausmaterials553 land ints Z5534.Iuctrian A.95ifde Califon
nits no, &Safely Code,Sadaohat iti255]3rod25334.1 Us notiaMNuifthtwilding
Jane not currently haw a motor.dm it is my msponsihiliry a notify de axupwt of Nc
rcyuircmcnu ilhm\hemetph nrssuwcCtc,ccrihcam (Occupancy. p o pelican Date
ow r a cd agent j m All roof v s o be Class"B" or better
CITY OF CUPERTINO -
FURNACE/AC p
CUPEI�TINO PERMIT APPLICATION FORM
APN# 236 Q Date:
Building Address:
Owner's Name: Phone#:
e 3
Contractor: Phone. License#:
.2 Y, 20
Contact: Phone: Cupertino Business License#:
(/ -y IS R,42�t
Building Permit Info:
i�w_)
Bldg ❑ c Plum Mec1�I E
Job Description:
1 � , e AL A 2 0 SoA
Residential ❑ MmVnercial ❑.
For Re idential I llations:
Attic LJ ls`floor 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structuralEl calcs)
Structural Calculations required for new installation
New installation Planning Approval Required El
Cost of Project: Type of Construction: Occupancy group:
00
Strapped ❑ On Platform LJ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement
Qty. if
A e 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 i
BSEISMICRE Seismic Fee Res BUILDING
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
BUSLIC Business License BUILDING
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