03100004 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT a CONTRACTOR INFORMATION
BUILDING ADDRESS: DAHL PLUMBING CO, JOHN F PERMIT_N0.0
Q141 14TTICRIEST RD
OWNER'S NAME: 329 ALMA ST PERMITLSSUEDATE
ROGER WING
"E' (650) 321-5500 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'Int C� 0 0
00
LICENSEDCONTRACTOR'SDECLARATION
LmF 1 hereby affirm Nat I am flhe Bo under ndFoons of Chapter 9(commencing Job DCSCrIp[IOn
`2 ry with5c�tion]f1IN1)of Division Jof the Businelaand Professions Code.and myli¢nseis
Tomo ham merr V/ Q REPLACE 2 FURNACES
in fall s Lc.x
;moo Dam Com .1 nr INSTALL 2 NEW A/C SYSTEMS
M `& ARCHITECTSD R ON
,Elu 1 un rs,and my pians shall M used u nuMic acords
•u G Licensed Professional
r.in
pg OWNER-BDILDER DECLARATION v`
j<S 1 hereby affirm,hal I am exempt from the Comma or's License Law for the \'a
O o following reason.(Section 703 1.5,Business and Professiorss Calc:Any city or county
e m f which requires a permit,o commul,aper,improve,demolish,or repair any slmclam
u2i
poor to ltsissuance.also requircs the applicant for such permit to file a signed statement
,hal he is licensed pursuant Sq. FL Floor Area
a< ioValua�Ipg350
`t-$ (commencing with Scclion 7001 of Division 3 of the Business and Professns Gyk)a 1'
- that he is exempt memhont and the basis for the alleged exemption.Any violation of
Section 703L5 by any applicant for a permit subjects the applicant o a civil penalty of 3ABH SiBISI�CC 0
not MOM thanfin hundred dollars(S500). - .... Occupancy Type
❑ 1.at owner of the Limitary.or my employes with wages as their sole compensation, -
willdothework,and the structure is not intended a, Rend for late(See.7040,Business R �1- per{
property it P.Asomm;Code:he Cminctor's License Law docs not apply to an owner of 3 01 - ROUGH Pe�Nd Ing -
h builds or improves thereon,and who does such work himself or through his
Own employees,Pooided that such improvements arenor intended Or offered for.vlaIf. 303 - ROUGH MECHANICAL
however.the building or improvement is sold within one year of completion,me owner- -
builder will have the burden of proving that he did not Wild or improve for purpose of 304 — ROUGH ELECTRICAL
sal..).
01.as owner of the proper,am exclusively concocting with licensed contractors to 505 - FINAL ELECTRICAL _
construct the Project(Sec.7044,Business and Professions Code:)The Contractor's Li. 507 — FINAL PLUMBING
cense Law dao not apply to an owner 9f pmynny who builds of improves Human,and. 508 - FINAL MECHANICAL
who contracts for such projects with a con,racreuthe
rfs)licensed purauano Canvai s
cto
License law.
❑1 am exempt under Sec ,B&P C in,,his lesson
Owner Dale
WORKER'S COMPENSATION DECLARATION - - -
1 hereby affirm under Penalty of Perjury one of the following declarations:
I have and will maintain a Cenificere of Consentto self usam for Workeri Compen- _
salion.as provided for by Section 37W of the tabor Code,for the performance of me
work for which Nis permit is issued
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code.for the performance of the work for which this permit is issued.
My War Co �ensa,i 9lnzunae artier and Policy number
Cam Policy No.:
A IF
CERTIFICATE OF ,fEMPT10NFR0 RKERS'
COMPENSATION INSURANCE
or less.)('Thu aecumn need not be completed if Me permit is for one hundred dollars is 100)
I cmify that in,he performance of the work for which Nis Permit is issued.I shall net
employ any person in any manner so as m become subject o the Workers'Compcve orris
Laws of Califomia.Dick
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificate of Exemption,you should
become subject,o the Worker a Compensation previsions of Oc laha Code,you mus,
,z forthwith comply with such provisions or this permit shdl M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
-� 1 Wrens ofErm that there is a construction lending agency for the Performance of
1' the work for which this permit is issued(Sec.307,Civ.C.)
i1 lenders Name
Lender's Address
Z) Z
J Q 1 cenify that I ban read this application and state that the above information is
y F-
' Comet I agree m comply with all city and county ordinances and slow laws relating to
',U building construction.and hereby outhouse rcpresenulivea of this ei,y to enter upon N.
oned
W ab0voes,judgmns,cost fond caLenion purposes.
_ gy (We)agree 10 save.indemnify ears keep harmless the City of Cupertino against
Jzh tocomes.judgmc t 0 granting eapcnseemit, may in any way accrue against said Coy
in cone c0rthc granting of,his permit. �—v
~ SOPLI- UNDERSTSANDS AND WILL COMPLY WITH ALL NONIO NT Issued by: 0�6
Dale
Re-roofs
,m9mdpm!75LAEpp1.cimUCmUraUUo De,.
HAZARDOUS MATERIALS DISCLOSURE '(Type of Roof
Will the applicant or future building acupan,score or handle ha2Nous..,hot
a defined by the Cupenino Municipal Code,Chapter 9.12.and the Health and Safety
Gale.Section 3553](.)?
❑rex
O'er
All roofs shall be inspected prior to any roofing material being installed.
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
it hemostat air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
5111,3?
0Yes ❑Nn
I have mad the hionedeuamourials requirements under Chapter 6.95 of the Califor /
nixs ealth Or,
Solt,Cade Memo.Los( 55Aand255J4.I andersonor M.M. d cMet MethctOfthe - T _/
Jas no,c rtcnlly have tenant.Nal i,is my rspur¢ibilily u,until' .Me Put of the _ V
MxMMM ,. drt=rept . 1i.1,u;ssa,ne.ara��/`a scut, Signature of Applicant Date
Owner or aumonued agent 2 �� D„e All roof coverings to be Class "B”or better
CITY OF CUPERTINO
�CV FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN# 3 2 — /6 — St _ Date:/O
Building Address:
Owner's�ame: hon #:
v3 LI7G - l�rq
Contractor: ,'� p ' II / Phone/:: Lic se#.
SU - - ' j�u h f (`1G y� „�-'�-C7o �o d
Co ct: ?P P ne: Cupertino Business License#:
( a ,r &A,s ��i� Ss� 3
Building Permit'Info: /
Bld� Electz PluMK"fi Mech
J Desc iption: L
c
Residential 15k Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor❑
• Adhere to min setback requirement[]
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
S aural Calculations req ' d for new installation Eleuw installation Planning A oval Required ❑
Cos of Pro.ect: Type of Construction Occupand, gr r
o
Strapped LJ latform ❑ Bonded ❑ Sq.Ft. Floor .
New Location ❑ Replacement
Qty. if
A ca 1 Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
/ABREMACOVER 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
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING