03110067 (2) I CI'T'Y OF CUPEwrINO ,.,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: SAN JOSE AIR CONDITIONING PERMIT NO-03110067
6354 BLAC WOOD DR
OWNER'S NAME: 880 N. 8TH ST. PERMIT ISSUE DATE
IAN OGLESBY 11/13/2003
NEI (408) 286-2047 SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
loo
LICENSEDCONTRACTOR'S
under DECLARATION _
U F 1 hereby affirm that 1 am licensed under provixiu s nr CAaptcr Y(commencing Job Description
E=N w;1hSCctien70 � fD1VilOn3orthCBOilnssand I IORtGOd. dmyllCCn411
mufn :eNy�r�a� "q REPLACE FURNACE & A/C, ELEC"PINAp em
>,y,? LiccnuC Lt.p
=Fp Dale Comma
£H ARCaITECRSDFARATION
E W u 1 under an�ykpY�Ilyuusc as pubHt records
FEB
a Licensed Professional / r 1 �O 04
ca< OWNER-BUILDER DECLARATION
<ST 1 hereby affirm that 1 am exempt from Ne Contractors License Law for the ®�'. S'�
p o following mason.(Section 7031.5,Business and Pmfcsnions Coda:Any city ar county ® ■`GL/1
which requires a permit in construct,alter,improve,demolish,or repair any uruauu 4 0
^i„ pnono i,issuance.also requ;res the applicant for such Permit o file a signed statement
<
that mislieensetlpursuanllothe rivisim¢ofthe Contractor aLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
2�a (commencing with Section](NIO)of Division Sof the B usinces and Professions Coca)or 36917052 . 00
Nat he is exempt Ihcmfrom and the lines for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicinuo a civil penally of AFSN Number Occupancy Type
not more man RW hundred dollars($500). P Y YP
1,as owner or the property,Or my employees with wages m their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Councilors License law mei not apply to owner or Required Inspections
property who builds or improves thereon.and who does such work himself or through his
own employ.,provided thin Such improvements are not intended oroRened for site If.
however,the building or improvement is mid whhin one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the pmject(Sec.7044,Business and Pl ofcisiomi Code:)The Contractor's Li.
cove taw docs not apply to an owner of property who builds or On pmvm memoo,and
who contracts for such projects with a contractor(s)licensed pursuant o the Cannelton's
License law.
❑ 1 am exempt under Sec. B At P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of Use following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker'sCompcn-
7371M
pn,u provided for by Section 3700 of dx later Code.for the perPoamorm.of the
rk for which mia permit is isamil.
1 have and will maintain Worker's Compensation Insurance,ss required by Section
of the labor Cotle,far the performance or the work for which this permit is issuedWorkc' omp satin Insumna conic otM P y nu�slMra r 01 ` f
CERTIFICATED EXEMMO FROMWORKERS'
COMPENSATION INSURANCE
Mix Section need at Meompleted irme Permit is for one hundred dollars($100)
or less.)
1 Sentry mat in the perforroanea of the work for which this Permit;s issued,1 shall not
employ any person in any manner an as at became subject to the Workcri Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:if.after making this Certificate of Exemption,you should
become Subject to the worker's Compensation pmvinov of the labor Cour.you moa
z forthwith comply with such provisions an this permit shall be deemed mvokcd.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm mal mere is a conswction lending agency Or the performance of
the work rur which this permit is Wood(See.3097,Co,C.)
W 0 Lender's Name
= z lender's Address
U O I Senify mat I have read this application and sed"
that the shove information is
Pcontact.I ague to comply with all city and county oNidem.a and Scale laws relating te
0U building construction.and hereby authorim representatives of this city to enter upon the
� alible-mentioned property for inspection purples
Fin co%j liabilities e)agree tnto cos,internal
nt mpcnuswhie harand kep ridan to Caty of accvcapertino against
U'Z Y Y Y against said City
vc of the granting of this permit.
^
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS. ,
:wren Appl"anVFtbr Contra ✓Y a Re-roofs
te
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the aPPlicam or future building occupant score or handle havmtlous material
as defined by the Cupertino Municipal Com.Chapter 9.12.and the i and Safety
C.Section 25532(:)?
0y. PNo All roofs shall be inspected prior to any roofing material being installed.
'
Will the applicant of 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 contaminants ss defined by the Bay Arca Air Quality Management all new materials for inspection.
;atria?
❑Yes XNo
I have mial the hvaNtms materials requirements under Chapter 695 of the Califor.
does
an ateatiov2terit1 myoand2S534.l in molly Ithmifthcnt or
r
docs not ms whit has:a tenant(mal it is sac neipor a eery, notify the occupant of the
mquiremen,which mow mel pnos,w;ssnantenn cntirtmte9r, Oc Signature of Applicant Dale
r
t
U5i;offl adivin.il agent Date All roof coverings to be Class "B" or better
FROM :Mary Kurtls `?r' FRX NO. :415 276 2304 'Jul. 06 2003 03:21PM P1 `
CITY OF CUPERTINO 63 ( 1 /
FURNACE/AC
MPE NO PERMIT APPLICATION FORM )
APN# Date: 1 31
Building Add Lwx
Owner's Name: phme
,t 1 c5L�S�i
Cu,i [or� /�- phone{ :, � a Ol L
Contact Phone: rtino Buts cense#:
L
Building Parona Infe:
Bi ❑ Elect ❑ } Plumb
D Mach 13
Job DmrljNlon:,Z 1i�Cft— lam? fv r� C� JE,UEZ,�U t-0
Residential ' Commercial [I
•
For)ieskle LJ
IuatLJallafl13 ,
Artie t flo[x Td floor
Adhere to mitt set back uirement❑
For Comaterchd Installatiom;
IReplace,ttdtt same weight ❑ Additional weight(sLund calcs)
Structural Calculations mquimd tar now installtaion LJJ
New installation A uired rlM
Cost of Project I � Typo of Constrastion; ocaipitncy up:
Strapped On latfonn 11Bondod C3SgYt.Floor
•NewLtxtttitm ❑ Re latxnlettt ��•
Anif
] We pei ID Pee DescriptiGn Fee Group
BENEROY Energy BUII,DING
BRBMPURN Relocattioa of Furnace' MECHANICAL
BREMACOVER A/C Unit y 10,000 cfm MNCHANIC:AL
BREMAWLkN A/C Units<- 10,'000 cfm MECHANICAL
TlRFMRW.FP'r d,Switch&Outlets ELECTRICAL
BSMMICRB Scismic FCC Rcs' WELDING
5ERMIITF1 Rkc Permit ksuance ELECTRICAL
c MpERivinnE Mech Permit L%ua= MECHANICAL
PPERMI RE Plumbing Permit Issue PLUMBING
$pEkMFEE Bld Permit Nees BUIWING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUI MING
` R P
Customers Name Crossan, Keith - Wcvd From Sears 11/6/2003 t
Address .2690 44th Ave ._ i
San Francisco 94116 - Value $11998.00
Sob No. -3391049 A
Customer Ph.. (415) 664-1102
Department Windows
MBNA? Permit Fee ... Business License Fee
Copies' R L Mileage Postage
Post to Job Site QO photos A Q 1> Plot Plan U
To Customer To Sears
Final Inspct Set for H'Ownr Notified by-
Final Inspct Set-On.- 11 stoke W/ H'ownr
• ' , a.' — LR MSG on Machine -
Lit MSG W/ Family Mb
Notes l�`t\C:�O�J
�- !-�W ��N� . Canty � 6�-�•iJ� s1�xv.k�;. -
i
Saturday, November 08, 2003
Page 121 of 565
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