05040085 (2) CITY OF CUPERTINO ,aa:+a•��•
BUILDING DIVISION PERMITaCONTRA.CTORINFOItMATIO,N k
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BUILDING ADDRESS: ALLIED AIRE SERVICE INC PERMITND05040085
20377 CLAY ST
OWNER'S NAME: PERMrr ISSUE DATE
MARTIN KELLER 661 SINCLAIR FRONTAGE RD
NE: SANITARY NO. CONTROL NO.
(408) 934-8844
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0
cavo LICENSED CONTRACTOR'S DECLARATION
r u F 1 hereby all Nu I am licensed under provivnns of Control,9(mmmcncing lob Description
p, with Section 7")af Division Sof the Business and Profession.Code.sadmylimpecis
n�aor rail rameand acs REPLACE FURNACE & ADD A/C
s a: Lieen tCj - o,aa.3$Contractor
�aa3 S
tFp Da¢ TSDECL
As mailE used a public
1 understand my plans shall W used u public rccarda
tau `
''a LiccnuI beach,iaml c
.�105 OWNER-BUILDER DECLARATION vyyl`y/
00 1 Wmby affirm on 11. exempt Ilium the Carnal Co License Law for the !1
OO following Bunn.Permit
703 1.5. and improve.
cortins Code:Any city or county
$ which syusoae.also I.reclaims
thaalterimprove.demolish,or.,ana sig anyumcros
Fib that hor e incensed e.almmquirm thovisiosatcant for such Cortrormiuorlese Laed w(shaptert
that me cingwitpursuanttolWofDivionsnfthe eBuxessai<nuhw(C com)or Sq.Ft.Floor Area - Valuation
a�0
that
(commencing it Uplamorand)the
basis for
oft al Business and Professions Cale)car
i�$ Nat he u exempt IMrtRmn and da buts for Bre alleged eumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of erO 0 Occupancy Type
not mos dran raw hundred dollen(ML
❑I,as owner of the property,or my cmployccs with wego as their sole corepenution,
will do Ne work and the.Swcma is not intended or attend for sale(Sec.7044,Business
and Professions Code:The Contractors Liceme law does not apply to im awmr of Required Inspections
property who Wildsorimprows thereon,and who doessuch work himselfor through his
Own cmployou,provided that such improvements art not intended proffered for sale.IL
however,the Wilding or improvement is sold within one year of completion,the owner-
builder will have the burden of proving Nat be did not Wild of improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contraction to
canswct the Project(Sec.70x4.Business and Professions Code:)TW Carvacrols Li-
cense taw does not apply in an owner of property who Wilds or improves thermal.and.
who contracts for such projects with a conuactor(s)licensed pursuant in the Contractors
License Law.
❑I am exempt under Sec ,B&PC for Nis amort
1301'
wrar Dare
WORKERS COMPENSATION DECLARATION
1 herby affirm under penalty of perjury one of the following declarations:
G
1 haw and will maintain Section
37Mficran of Consent toCode.for t forerfoorWorker's ce of the
tion,u provided for by Section J7o0 of the labor Cade.for the performance of the
ak for which Nis permit is issued.
I have and will maintain Workers Compensation Insurance,as stained by Section
00 of the Labor Cade,for the perfm rtmee of the work for which this permit is issued.
y Worker's ea.rsnD�ensaTtion�lBg�rassurnnec carticr and Policy number amq.�.��mnm:lVt^�ts�f /Va't 4.Jh�Policy No.:CA I'aR'u/� 'r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mbis section need not he completed if the Permit is farane hundred dollars(SIM)
or lcssJ
1 certify that in the performance of the work for which this permit Is issued.1 shall not
employ anypleu n in any muocno as in become subject to the Workers'Compensation
Laws of Cithfamia.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject to the Worker's Compensation provisions of the tabor Code,you must
0Z foMwith comply with such pmvi,iom or this pc.I, hall W dcemed revoked.
'ZO CONSTRUCTION LENDING AGENCY
F`� Ihereby affirm that thea is a construction lending agency for the perfurmence of
pe. the work for which this permit is issued(Sec.3097.Civ.C.)
V]Q Under's Name
a
Z Lender.Add.
U
U Q 1 modify that 1 have mad this application and some that theand
above information u
ly U cormtt 1 agree to comply n,and with all city and county porniv s of and cute laws slating m
p U alwyenmentioructio r&rty hereby infinitivep rposes.nutiru of this city to enter upon the
ITT ahovc(We'again
property for impaction purposes.
gy
(We'
egse to w,indemnify and keep mi'm m the City of Cupertino against
F" ACA
'me
mat
u and mea which may in any way accmc agmnst said City
U Z of lib gra tA 5 AND COMPLY WITH ALL NON-POINT Issued by: Date
0
3 1S a� Re-roofs
Si naturea'ApplicurlContrutor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occup intamm or handle ha ardous material
as defined by the Cupertino Municipal Cade.Chapter 9.13,and the Hcalth and Safety
ode,Sawn 15533(a)? All roofs shall be inspected nor to an roofing material being lis t5� P P Y g ginstalled.
Will the applicant in future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardoor air mnmmirunu u dcrned by the Bay Asa Air Quality Management all new materials for inspection.
Di icA
❑Yes C+ <0
I Wrhe harar nusmaterialsmquimmemsundcr ,Chepmr&95oftheCalifor-
niaHwl S cry Code, euonsu 05.23531 uu17553d.1uMersmM thvif lir Wilding
does a ensmP tly haw n Np 7tTsmrn a mbiI m ratify tW occ t of the
recut or
recut R mt miuvancco lairc�ma ase r S Signature of Applicant Date
Owner or aatherlaed e.er, •S (� un All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
I
Cupertino CA 95014
r
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
c73-Tt C1-6 —12c SD400$S
OWNER'S NAME: kr2TuJ G.Et.I_CV— PHONE # SS-
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating %v-e SLvx-
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
3 � ISoS
er/Contractor Signature Date
CITY OF CUPERTINO5
10 � B1Ri�IACE/AC o f"
:UPERT
INO PERMIT APPLICATION FORM
APN #sc, l 3 0 D Date:
Building Address: `(
ao3 -7 '? L-A
Owner's Name: Phone #:
Cont actor: Phone: License #:
L-L-<<y 4Ck X039-
Contact: Phone4n/O S Cupertino Business License #:
�12AJIC "fft�l Q
Building Permit Info:
Bldg ! Elect�a Plumb Mech
Job , scription:
c_c-- A c-
Residential CT Commercial ❑
For Residential In lations:
ttic ❑ 1" floor W 2"d floor❑
dhere to min set back requirement
or 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 C nstruction: Occupancy group:
12C-PLAC-C A((-
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicale 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMII'FEE 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 Licens `� BUILDING
i