03070219 (2) CITY OF CUPER'1'INO d^wsFtr.�n„ '+
g BUILDING DIVISION PERMIT I�CONTRACTOR INFORMATION �
%'IRT a -0a n .ate P�'fJL4'LAR''
BUILDING ADDRESS: CONDITIONED AIR PERMIT N%3070219
OWNER'S NAME: 1701 LITTLE ORCHARD ST PERMIT ISSUE DATE
ZHEN HU 2003
°NE: (408) 291-2220 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB WHICH
0 0 0 0
100 LICENSED CONTRACTOR'S DECLARATION Job Description
1 barely aIflom that I em licensed under provisions of Chapter 9 commencing P
with$mtinn lOxim.f Division3mrara Business I.I.ron ad mylicen s
Toren mine ad r�V g A/C (3TON) CIRCUIT FOR DISCONNECT
Liccn s
9 Dau Cu
e ARCHITECTS DECLARATION
< 1 unticrsunJ my plain shell bound u public rcmrda '
py
A C Licensed Professional
OWNER-BUILDER DECLARATION
f 1 hereby offmn that I am exempt from the Common's License Law for the
o O following mama(Section 7113:.5,Business and Pmfesstuns Code:Any city or county
$ which requires a permit to construct,alter,improve,demolish,or repair any structure 81188
prior or its Issuance,also requires the applicant for such permit to file a signed statement
< that he islicensed pursuant toasprovision ofbeComourmrsLoc
one Law(Chapter 9 Sq. Ft. Floor Area Valuation
ej C (commencing with section 7000)of Division 3 of the Business and Profesdams Coca)or
that he"exempt therefrom and the basis for Ne alleged exemption.Any violation or 36917019 . 00
Section?mlsbyany applicant for apermit subjecumeapplicant InacivuPenalty of APN Number Occupancy Type
not mom Nan Eve hundred delta.($500).- -
0 1,as owner of the progeny,or my employees with wages u Weir sole corepenss0on,
will do We work,and We structure is not intended ar offered fonale(Sec.7W.BusiOc'a
and Professions Code:The Conuachofs Limase law does not apply to an owner of 304 — ROUGH ns
property who builds or improves Ramon.and who does such work himself or thmugh his
owntmployces.provided that such improvements..of intended oroffered lbr sale.If, 505 — FINAL ELECTRICAL
however,We building or improvement is sold within one year of completion.the owner,
builder will have the burden of proving that M did not build or improve for purpose of 508 — FINAL MECHANI CAL
sale.).
0 1,as owner of the progeny,am exclusively contacting with licensed contractors to
construct the project(Sec.7014.Business and Professions Code:)The Conmcmrs U.
came law don not apply to an owner of progeny who builds or improves Barton,and
who eommem for such project will a contractor(s)licensed pursusm to We Common's
License Low.
01 am exempt under See .B A P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury,ow of the following declmtim x FIN®LEI
1 bats and will maintain a Certificate of Consent m sel6inn re for Workeri Cwnpcm �'1
cation,u provided for by Sccu n 37W of the Isbor Code,for the performa,ge of We DEC 1 2
work for which this permit is issued. 2003
0 I have and will maintain Workers Compensation Insurance.as required by Section
3000 of the Labor Code,for the performance of the work for which this permit is issued. /��s{���
My Workers Compensation Insurance artier and Policy number am: BUILDING
Cartier. Policy FROM
CERTIFICATE OF COMPENSATION INSURANCE WORKERS'
COMPENSATION INSURANCE
(This section(teed nm bccomplmeJ lithe permit is foronc hundred dollen($I0)
or less.)
1 sundry Net In We performance of We work for which this permit Is issued.I shall nm
employ any person in any manner m as in become subject to the Workcri Compensation
Law'of Califomie.Data
Applicant '
NOTICE TO APPLICANT:If.after making this Ceni Beate of Exemption,you should
become subject 10 We Worker's Compensation provisions of the labor Crude,you must
7 Z forthwith comply with such proyWons ar this permiuhall W deemed re olmd.
CONSTRUCTION LENDING AGENCY
1 tetchy aMon thin IMre ins conswninn lendin{egemy fnnbe performance ser
Y, thea work for witch this permit H issued(Scc.3091,Civ.C.)
QLanders Name
= z Laaderi Addm,,
..I Q I mnify that 1 haw mad this application and mte fast We above information u
y cmrecL I agree to comply with All City And county ordinances and state laws relating no
building conswction,and hereby mthorim mpreacntatives of this city to enter upon Ba
W show-mentioned property for inspection purposes.
(We)agree to an.indcmni fy and keep harmless the City of Cupertino against
ti fast liabllitts,judgment,costs and expenses which may in any way accomaaagga/aiiknstt mid
City
S URGE enccoftheg tiyof Wis pc y
" APPLICANT UND A DS D COMP WITFNALL ON-P INp Issued b : Date
SOURCER U
Re-roofs
Signature of AppinandComramor Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or haMlc havaNeus material
as defined by the Cupertino Municipal Cabe.Chapter 9.13,and Is,Health and Safety -
,siskow. � All roofs shall be inspected prior to any roofing material being installed.
Ye'
Will the applicant or future building Occupant use equipment ordeviccs which If a roof is installed without first obtaining an inspection,I agree to remove
in haurdons air contmiamu;As dcgncJ by the Bay Arca Air Quality Management all new materials for inspection.
istict't
❑Yes
I have mart the hazardous materials requirements under Chapter 6.95 of the Celifor.
nia Hcath myCodc,s tau 15.25533 J25534.Iundonmndthmiflhu building
dna not my Y it Is my pension m notify dte capon of the
m uor�` `y' Signature of Applicant Date
Owner of authorimrt agent Dn�� All roof coverings to be Class "B" or better
CITY OF CUPERTINO
FURNACE/AC j
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address•
Owner's Name: Phone k
253 -1,5-38
tract r; hone: License#:
Z
Contact: Phone: Cupertino Business License#:
Ji min-vi.a-
Building Permit Info:
Bldg ❑ Elect PlumbX Mech
Job Description: I�� J�O?ol �? /C, rQ, _
Residential u Comme`rcial ❑
For Rggaidential I liations:
Attic U 1$`floor 2nd 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
Cost of Project: Type of Construction: Occupancy group:
Strapped 0 On Platform ❑ Bonded 0 Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
1 BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
/ 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 LicenseDUJIJANG