03040013 (2) CITY OF CUPERTINO
a BUILDING DIVISION PERMIT ' CUNTRtLCTORINU.,. �' IU
h 571, �i
BUILDING ADDRESS; PERMITNO.
11306 BUBB RD A PERFECT CLIMATE 03040013
OWNER'S NAME: PERMIT[SUE DATE
KOPY HELEN D ET AL 10570 S DEANZA BLVD 04/02/2003
NE: SANITARY NO. CONTROL NO.
(408) 861-9545
GHITECTANIGINEEK: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
�oI LICENSED CONTRACTOR'S DECLARATION Job Description
r� 1 heroby afOrm then 1 am Iiconsed under providona of Chepter 9(commencing p
with Saction 7qD)ofDMdon]of the Budrwnaed ProfeWons Code,ad my Iicenseh
LOnfaneande IS INSTALL FURNACE ADD A/C �f��LtE®
Lieen 1 c Lk.• v
B1g- Dam ARCHrMcr3DECL5 A N APR 1 8 2003
I understand my Plans.hall he used a public reearN
3 Licensed Pndeulonal
OWNER-BUILDER DECLARATION BUILDING
t P I hereby.(Seat than 1 I.S.Bumph from Pr Cantnmar'a License Lew for theBUILDINGD O
which
recon.permit
7031Business ad borrow.de oli Code:My em m canny
$ which inquires•permlo to consuue4 time forsudemolish.t ri repair ed uIncturt
y,+ that heprior its licensed
issuance.eluantso in t e pro visions of forsuch to Tensele a La ed statement
<
that hehlkensed pmswnt 70th)of Division
the eBusin mYL3mNa1sio(chaptersode) Sq.F[.Floor Area 9 T IOn
G
(commercials aisexempt
pt theniom and t f DlaWon]of theBusinessexa pl Professions vi lation $9 �i�
33� But he D enmPt�fran and the beds for me dinged eumpdon.My vialnian of pp����.II t5j
Sema 70]1.5 by tin applicant for a permit wbjcou the applicant to a civil Penalty of 3-6"LU ti � 0 0 Oeeupaney'Iype
mm
not mom fin hundred dollar,($500).
❑f.uownmofthepropeny.mmympio wiNwagesutheb Inkcompewdm,
willdo the work and mesuunurt haUnmnded mattered fmak(See.704a,Business
and Proresdmu Code:The Commomes LIm into
com a law dean apply an owner of 301 — ROUGH RpgW nglli HenGn3
pmpenywhobuildtorlmpmvudmmokandwhodmatmhwork hImWforW 11this 303 — ROUGH MECHANICAL
ownemployeea,pmvided that Inch Improwmcou art nminmMed maRered fmak.If,
however.thou building or improvement is said within one year of completion.the owtmr- 304 — ROUGH ELECTRICAL
udburcot
der wall tun the den of proving that he did build m Improve fon purpose of 505 — FINAL ELECTRICAL
❑1,as owner a the property am eeclmlvely contracting with licensed contractors to 507 — FINAL PLUMBING
coMmct the project(See.7044.Business and Profusion Code:)run Contractor's Li. 508 — FINAL MECHANICAL
came law does nm apply to an owner aproperty who builds or Improves therton,and.
who co ssom fm such pmjecu whin t canuutoKO licensed pmauat tothe Contratar's
Limns law.
❑lameeemptunder Sea .BkPCfmthisreaon
OwerDECLARDam
WORKERS COMPENSATION ATION
1 hereby affirm under penalty of perjury one of dm following dahndunc
have and will maintain a CenlOeamofConsent to self-Imum fm Worker's Compen.
on,u provided for by Section 3700 of the labor Code,frr the perfonanm of the
for which this permit Is lured.
haw and will maintain Worker's Compensation Insurance,a refulmd by Section
I n
of the Labor Code,for the performance of the work for which this permit is Issued.
My Worker's Compensation Insuo nae carder and Policy nu r art:
Gaoler.A Policy No.: I`tu3�
GERTIF7GA7EOF IEMPTION FROM WORKERS'
COMPE ATION INSURANCE
Gbh atom reed not W campleted if the mann is froom hundred ddlaa(5 100)
m less.)
1 certify that In the performance of the work for which this Permit Is laud,I shall not ,
employ any person In any m mm rad as to become subject to dm Workne Compensmon'
law of Cdifomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenifiuu of Exemption,you should
become subject to the Worker's Compensation provisions or the Labor Code,yon must
.,O forthwith comply with won provisions or this permit N deemed mucked.
r CONSTRUCTION LENDING AGENCY
j-n l hereby affirm dust them is a conamOnn lending agency for dw Isrfmman eof
94 the work for which this permit Is issued(Sac.3097•Civ.C.)
G Q Lender's Name
a z Lender's Mdros
I mrlifY that 1 haw rad this application and soon that the show infatuation Is
L)0
IL coon.I agrte to comply with all city and county ordinances and rete laws missing to
G building construction,and hereby autharlse mpmsematiws of this city to enter upon the
W ahme•mentio pmperhy for lnspeedon purposes.
(We) to an,indemnify and keep homeless the City or Cupertino agaiM
s:rt raA I1 idu,ju meAn
s dexpena which may In anyway acme against Wd City
V 7 in conseque ceng of this permit.
G7 APPLICA ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S URCE S.
a O Re-roofs
Signuu tic onuactar onto
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or factum building aaupnt cure or handle haadou material
a dellned by theCuperdan M Idpai'Eode,Clupuer 9.17.and tier Health an Safety
Cade,Semen 2553347 / All roofs shall be inspected prior to any roofing material being installed.
❑Ya
Will the applkat m future building occupant um equlfmal or deviDa which If a roof is installed without first obtaining an inspection,I agree to remove
It human= it conumin dfRned by the Bay Am.Air Quality Management all new materials for inspection.
vim?
[]Yes No
I how the MuNnusmaterials requirements undcrChapter 6.95oramCarol.
niaHulthk ray de.SCCU=25305,25533ad25534.IwWomAndlhuiff building
dom int c ntl M a"ML that it h my tespoaibility to unify the Moment of the
he is eh WbCmClpnarmiaYNWafaCtNgag Fm Signature of Applicant Date
Ower ran orb Feral `/ d- Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO 6 3 0 a
C U 'r KIT 1N.') PERMIT APPLICATION FORM
"N# 3(0a - Oc00 -ate Date: 03
Building Address �, I
1C1� •
Owis Nno aFne:
C tractor: / ' License # 3'
Contact ! Cupertino Business License #:
4
Building Perms'Info:
Bldg ❑ Elect .Plumb ❑ Mec
Job Description: ��eUj Ct
Residential \ Commercial ❑
For Residential Installations:
Attic ❑ 1' floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
• For Commercial Iust Ilations:
Replacementsarne-we t Additional weight(structural calcs) ❑
Stru al Calculations re \i d for new installation ❑
Ne installation Planning A 'roval Required
C st of�oje • TypeC nstr�ction: Occupancy group:
L stmt
Stra _--On-Platform LJBonded LJ Sq.Ft. F16or Area:
New Location Re lacemenII
d
Qty. .
App ca Il 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
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