05050082 (2) CITY OF CUPEWrINO >-,gym s "` `^-''� "
BUILDING DIVISION PERMIT CONTRACTOR`INFORMATION
auaowcnoDRFss: PERMIT NO.CONDITIONED AIR 05050082
OW NER'S NAME: PERMIT MUE DATE
i (4nq) 2qj -299n I
ONE: SANITARY NC7 C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O p
u00 LICENSED CONTRACTOR'S DECLARATION T,,a,TT11
w I bereby ifrrm rho 1 am licensed under provisions or Chapter 9(commencing Y sCrlp[]On
iw withllforc Section ivision 3.fft Busincaaand Profcssiom Code.and mylimnm is ®®
��„ inr,Bfmceanderr�{t .hyo REPLACE FURNACE ek}=�t
x Licenu Class `"—�Q Lie.N
DECLA
Dow
5( IF/lJ� ComranorTIC
R
ARCNITECI'S ATION
I undcrnand my plans shall be used as public¢curds
;at Licensed Pmr.mioml
-� 2005
S OWNER-BUILDER DECLARATION f�p rs�
K<� I Maso a(Trm on I am exempt from IW Contractor's C Licenu law for the [[trt.i�r t]q�f/]ry
a O folwhich
re reama omiI t ]cont, t,Business and P(e.de oli Collo:Any oily err county K v, which myuirm a permit na construct,alcor.impmsu h cronitt or mash ed tatuetum
prior us its issuance,also requires IW applicant for such permit m file a signed statement
W—x�x¢
that he is licensed pursuant m the provisions of NC Contractor's License law(ChapmrY Sq. Ft. Floor Area alua[on
memonencing with Seelion]000)of Division 3ofthe Business and Promasiom Code)or
.yet at he u asnmpt th¢from and the basis for the alleged eaemptinn.Any violation or
Section 7071.5 by any applicant for a permit subjects the applicmuo a Civil penauy of 3i,y-awWvT,.ws1.�ro0 Occupancy Type
not more than five hundred dollars($SLID). O'R Wvl U�t�r3�
0 1,as owner orthe'.pony,or my employees with wages as Heir sole compensation,
will do the work,and the structure is not intended or offered formic(SIL.70W,Business
and Pmressiuru Code:The Ccaumcmi's Li..law does nut apply In o owner of Required Inspections
property who builds or improves thereon.and who docs such work himself or through his
own employees,provided that such improvements us not intended oroffered for axle.IE
however.the building or improvement is sold within arc year of completion,the owncr-
builder will have the burden of proving that he did ma Wild or improve for purpose of
sale.).
Q 1,as owner of the pmpeny,am exclusively contracting with licensed mnvacmrs Or
consumer the project(Sec.7044,Business and professions Code:)The Contractor's Li
come law docs not apply no an owner of property who Wilda or improves simmer.and
who contracts for such projects with a contraco,(s)licensed pursuant to the Contractors
License law.
❑1 am exempt under Sec. .B&P C for Nis.mon
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hemby aRsm under penalty of perjury one of the following dedantions:
1 have and will maintain a CenlOcam of Consent to self-insum for Worker's Compton-
her,as provided for by Section 37M of the labor Code,for the performance of the
W
ork for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as rtquired by Section
7]00 of the tabor Cotler for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier.��RTC(�`SG1r I IICTIC Polity No.: 7(� I Cl
s.ctt,I AFiC TE bFE%EMP770N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if she Permit is for one hundred dollars($:0()
or los.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner ser as an Wcome subjecuo the Wofkess'Compensation
Laws of California.Dao:
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption.you should
become object in the Worker's Compensation provinons of the IaMr Qtle,you roam
.,Z foMWhh Comply with such provisions or this permit shall be deemed tevnked.
Z O CONSTRUCTION LENDING AGENCY ,
(-. 1 hereby affirm Nu them is a construction lending agency fat Ne performance or
y' the work for which this armit is issued(Sec.3097,Ci,C.)
CQ Tondo's Name
=z Undoes Address
J C) 1 certify that I have read this application and sum that the aura information is
Fcorrect 1 agree to comply with all city and county ordinances and sou laws misting to
U building construction,and hereby authorio mpmacnutivea of this city m cumruPnn the
r W aW.-mentioned progeny for inspectionpurposes.
(Wo)agree to saw,indemnify and keep harmless the City of Cupertino agaimr
,F.� h liabilities,judgments,costs and expenses which may in any way accorc against said City
UZin consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS
5//11 /O Re-roofs
sig rc of Applicant/ .nvacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will IW applicant or future Wilding occupant more m hurdle haeardous material
m dcfmc0 by the Cupeni no Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yon �Nu
Will the applicam M fumrc building occupant use cquipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
-mit hai minus air contaminants as declined by the Bay Area Air Quality Management all new materials for inspection.
Diufics?
Ors off°
1 have mad the hanaN wsmamrials mquimmenu under Chapter 695 of thc Califor-
niaHcxlth&Safety Code.SecuumnS6.25533and 25534.1 undcrsund lhnifthe Wilding
dem not currently haw a tenant that is is my mapomihility in notify the Occupant err the
roger which mmtbemRI u...uVf.cersraa�eor«cepamy. Signature of Applicant Date
ZA4. <'; e.� S/ r'E 6 /O� All roof coverings to be Class"B" or better
Ow rOw r auth Dam
e Community Development
10300 Torre Avenue
J Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #6SOS00$
1013(b I ' �J
OWNER'S NAME: Win PHONE # &M)
- Q
GENERAL CONTRACTOR: FAX # C�cB) /-
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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ n or Signature Date
CITY OF CUPERTINO V Z_
FURNACE/AC
�UPERTiNO PERMIT APPLICATION FORM
APN # /; OI' Date: 05 146 lds
Building Address: 1
l0►3 Cb e soy
Owner's Name:Contractor: PhonL77TPhone
cense #:Contact: Phone: upertino Business License #:
h:t,�ce 3LI
Building Permit Info:
Bldg ❑ Plumb ❑ Mech ❑
Job Description: V 1 C
Residential ZC4 — Commercial ❑
For Residential Installations:
ttic ❑ 1 s` flo�2"d floor❑
dhere 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:3 Type of Construction: Occupancy group:
`1OC� -
Strapped El On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A licable Fee ID Fee Description Fee Grou
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 c8n MECHANICAL
BREMklIUiAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
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 Licens BUILDING