03060035 (2) CITY OF CUPERTINO d°' ' �•w�r, s '�zr'� ' � `''3. '� f��,f}�
BUILDING DIVISION
PERMIT C�NTRACTORTl }IAI�N
BUILDINO ADDRESS: A h HEATiNU PERMIT NO0 30 6 0 0 3 5
r 21716 COLLINGSWORTH ST
WNEWS NAME: 770 HESTNUT ST �A11T��¢'�4/2003
WEN LEE
NE: 408) 2 79-0 722 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING IT INFO
BLDG PLUMBWjFCH
0
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
+0 I hereby affirm that 1 am licemed nMor provision at Clupter 9(commencing
with Seendo.7010)of Division 3ofdm Beat.and protseme Coda,and my he..it FURNACE & A/C (220 VOLT CIRCUI
In full forte and.Reel,, ,— ) "r9,4z4? p�g tI f�
L Dacmnse au CL Contractor I B 7H A L r
G11ARCHITECTS DECLA Tl N
l undersand my plan shall be used as public records JUN 0 9 2003
±03 Licensed Professional
N i E OWNER-BUILDER DECLARATION
1 artby spring that I am exempt fnm
Use CantruroYs License Law for the
RA O following reason.(Section 70313,Business and Proregio s Code:Any city or county BUILDING
.122 which requires a permit to consirval.aar,borrow.demolish,or repair any slmetum
�+ prior m its ieveneg.ale regains the.ppitm.l farsuch permit In file a signed wteaent
F G
that he it licensed fermanlathe provisionoftheConwcar'sUcerueLaw(Chapter 9 Sq.Ft. Floor Area 51MWtion
$ (commencing with Section 7100)of Division 3 of Ne Butmossand Protestant Craig)or
that he 1. basis
�..
Section 7071.5 by guy Appm�a for a permit subjects TheAPPIICNr the alleged 110 aCivil mostly Of
not mart than Bw hundred dollars($500). A ser n.Any vlosdogn of Occupancy Type
❑I'm awnr oiling property,or my employees with wgn a their tole compensation. _
w111 do the work and tlestmnum a mtinanded a of loam rorele(Sce.70e,Busirce
sad Profaesion Code:rte cmn.era's I.Icene law man not apply a an owner of 303 - ROUGH Rg9.D0*kse;j&ns
property who bulldsor improve thmam.and whodoessuch work himselforthnugh his 304 - ROUGH ELECTRICAL
oweemploytn.provided the such improwmanaase not in', a oRaad forele.IL
however,the building a improwmant Is ata wlWin on year ofcompledoo.the owner- 505 — FINAL ELECTRICAL
builder will 507 - FINAL PLUMBING
❑1,as owner of the property.am exclusively contracting with licensed mntracers a 508 - FINAL MECHANICAL
conwet the project(See.7044,Business and Pwfegiom Cade:)The Contractors U-
an=law don not apply loan owner of properly who builds or improws Wemon,and,
who contracts for such projects with ecommemne licensed Furman,an the Conlracaft
License L.-
1 a a exempt under Sec .B t PC for Wa mean
Due
WORKERS COMPENSATION DECLARATION
1 hereby affirm under money of perjury one of the fallowing declaradonr.
❑I haw and will maintain a CardinaleofConent a self-asureforWoftesCompen-
elion,a provided fn by Section 3700 of the labor Code,for We performan¢of W
work for which this permit is issued.
❑1 haw and will maintain Wattages Compensation Insurance,a required by Section
7700 of the labor Code,for the perfonanm of the work for which this Ismailia Issued.
My Warkees Compensation Inannce carrier and Policy number tie:
Cartier. 77t-(e G! Ili Policy No.: N&116 6fV 7
CERTIFICATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
(This section rcN notbecanpked ifte irsmh afaonhumred dollen(5100)
or legal
1 malty that in the perfarmanco of the work for which this permit Is issued.I wall not
employ any person in any manner so e a become subject to tie Workers'Compm,adn
Laws of California.Dae
Applieml
NOTICE TO APPLICANT.If.senor making this Cenificae of Exemption.You should
become subject In tha Warkat's Compensation paNieion of the labor Coda.You muss
O forthwith comply with such provifan a this permit shall he doomed revoked.
Zy CONSTRUCTION LENDING AGENCY
'(gin I artby affirm that siert is a command..lending agecey for de perfermagoa of
a r7 the work for which this permit a issued(Sec.3097.Civ.C.)
LQ Lendefa Name
z lamicesAddret
U O 1 certify the I haw mad this application and sea the the abuw intonation is
I,.F correct.I agree a comply with all city and county eminences and eek IBM mining In
0U building construction.and hereby authorise mpretenatiws of this city to enter upon the
W .hove-m.eined property for inspection purpmet.
(We)agree in sew,indemnity and keep harmless thou City of Common against
res liabilities,judgments.cow and expenses which may in any way sena.against said City
U,'Z In consequence of the sterling of this permit. ��
t-+ APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE q�GULATIONS.
lei Re-roofs
Slg�AppEmnucomxmt Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or rut=building omup risam or han dic husmoue materiel
10wncr
s donned by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safely
Wo,Section 25531(47 0�. All roofs shall be inspected prior to any roofing material being installed.
❑Yee
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit avamnus air mauminana.s dented by the Bay Ane Air Quality Management all new materials for inspection.
iwictT
0Yes 1r Nu
1 haw nae the heamow material require==under Chapter 6.95 of the Califon
or Health k Safely Cade,Sections 25505.35577 a ad 25534.I undcmea thelithe building
ean not currently haw a tenant.the it a my InpmuihilitY a gouty the occupant of We
yolmmena hkhmuebcmelpsior let aaamoracmdreaaor e'a-wpyry-�� Signature of Applicant Date
or anth cd a sent ���Osco All roof coverings to be Class"B"or better
7{' CITY OF CiJPERTINO o 6' 3�
FURNACE /AC .3
. UPEkTINO PERMIT APPLICATION FORM
APN # C Date: l —
Building Address:
d 111 t40 LjjAj S W0
Owner's Name: � _ Phone #:
LEr oaf
Contractor, - License #:
G G 30tfV73.
'Contact- Phone #:
DALE. s 79-07,2A
'Applicant/Contractor,
tor,
r rel G � G
r Building Permit Info:
?' Bld ]ec Plumb e
Job„Description: p_ Z c04VAKE�— rL A.p
Residential: 2-2ot T ( [ Commercial:
Sq.Ft. Floor Area:
f. $/Sq.Ft.:
Architect/Engineer: Valuation:
�, • e of Construction:
� Occupancy Group:
Qty. if
I
EPPERMITFEE
ee ID Fee Description Fee Group
Ener BUILIDNG
N Relocation of Furnace MECHANICAL
VER A/C Unit > 10,000 cfm MECHANICAL
HAN A/C Units <= 10, 000 cfm MECHANICAL
EPT Rec tl, Switch & Outlets ELECTRICAL
RE Seismic Fee ResBUILIDNG
EE Elec Permit Issuance ELECTRICAL
FEE Mech Permit Issuance MECHANICAL
RMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUIL11DNG