05020061 (2) CITY OF CUPERTINO "^ "!� y +`�•'`''�+�' ''�"� �""
BUILDING DIVISION PERMIT �jC0 NaTRA0TORjNFORMATION`,
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BU ILDING ADDRESS: THOMAS PLUMBING INC PERMIT NU 5020061
NER'S NAME: PERMrr ISSUE DATE
ONE: SANITARY NO, CONTROL NO.
C
8 736-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t 0 0
coo LICENSED CONTRACTOR'S DECLARATION Job Description
I-W C 1 hereby airum W I 1 am licensed trader provitimu of Chapter 9(rommmomms P
tJ with Salion7(00)of Division 3 of the Busircu and Profession Code.and my licmve is
^o'w
in force full rrFm. oy REPLACE PACKAGE HAVC UNITS
5 q z Licens clan Lii.g
n—p Dam,.' - - b Cantracmr
i5 ARCHI'IECPSDECLARATION -
Sa m i I undersand my plans shall Ito used u Public records
�a,U
o
Licensed Professional
w 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the,Comnctor's License Law for the
E20 following mason,(Section 70315,Business and Professions Code:Any city or county
which requires a Permit to consumer,alter,improve,demolish,or repair any structure 2200
F2 prior In its issuance,also requires the applicant for such permit to rile a signed statement
iso that he is licensed Parwantloshe provian.ofthe,comismAnsLet.Law(Charter 9 Sq. Ft. Floor Area Valuation
¢t$ (commencing with Section 700K)of Division 3 of the Business and Professions Codc)or
3 that M is exempt therefrom and the baso fm the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit wbjecu the applicant in a civil penalty,of 3 5e&NiTQtfitlbet0 0 Occupancy Type
not am Nan file hundred dollars(5500). P Y yP
❑1,as Owner of the property,in my employm with wages m their sole compensation,
will do the work sad the summure u not intended of offered for sale(Sec.7W,Business
and Pmfearions Cade:The Comm ones Limne law does not apply m in owner or Required Inspections
property who builds orimprovn thereon,and whodmssuch work himself or through his
Own employees,provided that such improvements are not intended moffmad for We.If.
however,Ne building or Improvement is said within one yea of completion,the owner- ' F
builder will ban the burden of proving that M did not Wild or improve for purpose of F �1
salt.). }
❑1,as owner of the propo rtY am exclusively convecting with licensed mnaacmm to ^
conswct the project(Sec.7044,Business and Profeuiom Code:)71rc Conuacmfs Li.
come Taw docs not apply in et owner of property who Wilds or Improver Con ora and
Lienee acts for such projects with aconuactof(s)Baved pursuamwthe Conuutofs'
License Law.
Lem aemptuMer Sec. .B&PCfar Nu reason
Data
WORKER COMPENSATION DECORATION -
1 bemby affirm under penalty of perjury ane of the following dodaratons:
1 ban and will maintain aCeNOcate of Consent to self-insure for WmkcfsCompen-
satiW on,m providedln for by Section 3700 of the Latin,Code,far the peAmmwce of the
n
wofor which this permit is issued. fI
❑I have and will maintain Worker's Compensation Insurance,is required by Sect1ion
T! of the Labor Cofar tnce he perfarroaof doe work far which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy n ber art:
Carver:74Oay%W_ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu scrim need nut hecompIctml if the Permit Is form=hundred do fans(SI00)
in Ins)
1 certify that in IW performance of the work fm which this permit u issued.I mull not
employ any person in any manner an as to become subject o the Wofkef£Compcmation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cer ifcata of Exemption,you should
become subject 10 the Worker's Compensation provisions of the Labor Code,you must
J O forthwith comply with such provisions or this permit shall W deemed revoked.
'ZCONSTRUCTION LENDING AGENCY
'r+� Ihereby sfirre that there is a construction lending agency for the Performance of
n: the work for which this permit is issued(Sec.3071.Ci,C.)
1 A Lendch Namc
= Z Lart e,Addmu
V U 1 comfy that 1 have free this application pr sod stile of the above infomaon t e
I ,r .erect.I agree ro comply with all city and county ordinances and state laws relating th
O" above-mmoomeemlan.and herebyInspection purposes. Of NIa Clly b[nl[r upon the
r VW above-(Wc)&m to sam for imnify an hats bice
(Wc)agree to cove,indemnify and tech ha in an the City memo
against
UZ
liabilities, theostsancxpemm which may in anyway accmc against mid City
t)z APPI-16ANTe afthegobbling of DSthis Per mit.
APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date l/ �•/
R 01
S �Re-roofs
Signature V nlrw of Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will are app'coal err forum Wild ilding occupant centre or handle harafdous material
defined by the C.1noo,Municipal Code.Chapter 9.12.and IW Health and Safely
de,Section 25332(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or rats building occupant arae m Air oro or drains which g
'emit District? nus air contaminants u dcrincJ by the Bay Area Air Quality Managcmcnt all new materials for inspection. ,
District?
❑Yea I-]No
I have real the haamhus materials requirements under Chapter 6.95 of the Califon
nice Heal@&Sadty Codi,Sections 25505,25533 and 25534.1 understand thm if the building
don not currently have Nnam,that it is my maponsiol ity to nobly the occupant of the
iasaaneenfa ceNrinteor Qeapaney. Signature of Applicant Date
oeeuthmh sin Data All roof coverings to be Class "B" or better
Community Development
4 10300 Torre Avenue
1' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
JUPEkTINO
Building De artment
JOB ADDRESS: c PERMIT # �o d O
V b
OWNER'S NAME:� I PHONE # �o
GENERAL CONTRACTO FAX #—7 3 g !Fn--
I
I am not using any subcontracto
Signature Date
Please check applicable subcontractors and com Tete the----.ving 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
er/Contractor Signature Date
,
i � CITY OF CUPERTINO,
FURNACE/AC
UPERTINO PERMIT APPLICATION FORM
APN # Da e:
3 7 tea / , US
Building Address:
o ��
D
ne 's Name: o #
C ntractor: Phone: License #:
ntac : e: Cupertino Business License #:
O 3
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Descri ion:
Residential ❑ Commercial ' j4 J—Gz vLA tuc sz�`cl � o�S A o
W' i ,� �9�f c W �9— —k_
For Residential Installations:
ttic ❑ I" floor ❑ 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations�,� szSS
Replacement same weight � Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Re uired ❑
Cost of Project: Type of Construction: Occupancy group:
Strapped On Platfo Bonded ❑ Sq.Ft. Floor s9
�h� YUv��LrS
New Location ❑ Replacement
i
Qty.y. f
A f e Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFLRN Relocation of Furnace I MECHANICAL
BREMACOVER A/C Unit> 10, 1 MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm 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 License BUILDING