05120071 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT GONTRACTO I1 �OATTC111) ' :
BUILDING ADDRESS: A & H HEATING PERMITNo.05120071
20100 LAS ONDAS CT
OWNER'S NAME: PERMITISSUEDATE
TAKEMOTO KENNETH T AND JUD TH770 CHESTNUT ST 12/14/2005
ONE: SANITARY NO. CONTROL NO.
(408) 279-0722
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30o LICENSED CONTRACTOR'S DECLARATION 7obDcri VOA
4 Ga I hereby sfflrm Wet 1 am Iiaved under Provisions of Chirac,9(commencing p
with Section 7000)of Division 3 of the Emblem and Profrasium Code.an l my liceaso is
ate„ in mumceand-fr _La W R & R FURNACE - ASCM14D
0 VOLT CIRCUIT
b Z_ Lietme Class Lk.{ O
— Dam canlruwr
As small use D public mcca
I understand my plain shell he used u public records /e�
�o Licensed Pmfcsimmal
OWNER-BUILDER exempt r DECLARATION
E A I bcrohy,(Sam that 1 1. exempt from We Csourtsn as License Law for The
i p o which re moron.Permit
t 71131.3,Business and w,de um Calc:Any clay or county
which requires a eennt re cnmwd alum mprow,h remit t ri s pair d umctunt $9500
—�y pdormist issuance,also requires the applicant for each permitmfile tai{rod memtnt
< Wet he is licensed Pursuant in the provision of the Contractors Lleense Law(Chapwr9 Sq.Ft. Floor Area ItTIVeNaluation
$ (commencing with Section 7000)of Division 3 of the Business and Profession.Cadc)or
Wan he is exempt therefrom and Me bub fa the alleged exemption,Any violetlen of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not orae than Ow hundred dollars(5300). T ccupancy Type
❑L u owner of Ne property,or my employees with wages as Weir sole compensation,
will d.the..,it.and the structure is ran Intended os offered far W.(Sec.7044,Business
and Profession,Coda The Communes License Law does not apply n an owner of Required Inspections
propeny he builds orimproves thereon.andwho doessuchwort himself orthrough his
own employees,provided Wel well improvement am notinetned coffered retail-If.
however,the building or Improvement Is said within em year of complexion,the owner-
builder will have the burden of proving that he did rot Wild ar Improve for purpose of
ales).
❑1,u owner of the property,am exclusively contracting with licensed cam uwn in
common the project(Sec.7044,Business and Professions Code)The Camomile,U.
comes Lsw dose not apply 0.n owner of propsurt who builds or improaa thereon,and
who conancu for such mallets with a eonuactor(O Ilcemed puasnt to the Connors
License law.
❑Iamucmptunder Ste .Bk PCfmthismasson -
Owner Data
WORKERS COMPENSATION DECLARATION
1 herby e1Rnv under penally of perjury arc of the following doolaruto e
1 haw and will maintain a Certificate of Comte to selbinsum fa WarkeesCompen-
L adon,as provided for by Section 3700 of the Tabor Cade.for We performance of the
work for which this permit Is Issued.
❑1 have and will maintain Winker',Compensation Imursnce.u required by Student
3700 of Ne labor Code,fm rte performance of the wart for which this permit is Waned.
My Worker's CampsmWon Insurance artier and Policy number are:
Carder.'flLe 4AC I n.! S Policy No.:&fI g t B w
CERTIFICATE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(Tbb section road not he completed if the permit is foanc hundred dollarm(SI00)
or lest)
I certify Wet in the performamc of the work far which this permit is lasmd,I shall not
employ any person in any manner an as in become subject to the Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:if,after making this CeniOcaw of Exemption,you should
become subject in the Worker',Compensation provisions of the Lobar Code,you muss _
vJ O foMwith comply with each provisions or this permit shall m domed revoked.
„'Z,r oCONSTRUCTION LENDING AGENCY
[—t l hereby arms that then is a construcdnn lending agency for the perfulmana of
a the work for which this permit is Issued(Sec.3M.Civ,C.)
QI ari Name -
7 Z Landees Addrtu
U Q I coldly that I ban read this application sib sum that the thew informed.Is
lL F corm 1 apo or comply with all city and county onimncm and see lave muting in
Q U Wilding construction,and hereby authodes representatives of this city to area upon the
Itl above-mentiamd property for impecmn puriroset
y (We)agree 1.mw,indemnify ad keep harmleae the City of Copeman.against
fA liabilities,judgments,coast and expenses which may In my wayaceru,agbw wild CRY
V Z in amegance of the panting of this permit
^•t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOUCEREG�ULATIONS.
Re-roofs
Si{nuurt ofApplica tcommosor—Tem Due
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant acre or handle hasrdem material
u Zacd by tin Cupertino Municipal Cede.Chapter 9.11,and rte Health and Safety
mt.Sectionz353uan All roofs shall be inspected prior to any roofing material being installed.
7mqdm ❑Yes 9r.
Will the applicant or future building occupant use equipment or device.which If a roof is installed without first obtaining an inspection,I agree to remove
ithmannm all conuMmnu a dented by the Bay Area Air Quality Management all new materials for inspection.
wic17
0Ycs t]J�
I hwc mad dm hmsnnm mmdais mquimmcnu under Chapmr6.95.ftht Califor-
HcalthhSafcayCode,Sccdan.25NU,73533ad33534.1undemad Wulfthc building
s
rool not how a nmthat it Is my mspomn ihllity redly the motmenl of the
uhemon which bcmmpriorw' u cora eldnmmef0caromy, SignatureofApplicant Date
�Z
Owner at awhodmd agcm -0 All roof coverings to be Class "B"or better
Dew
aCll
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
SUPEkTIN.0
Building De artment
JOB ADDRESS120 1BQ 'S PERMIT0S/ LOO--?
S/ Lvo--? /
OWNER'S NAME: PHONE # 2
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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile R
Owner/Contractor Signature Date
/ C
CITY OF CUPERTINO
FURNACE/AC
�PERTINO PERMIT APPLICATION FORM
APN# Date:
` 369 3o o39 ,
a: Building Address:
ao l oo 4As oq S CT,
u; Owner's Name: Phone#:o�s.3 O$•a 9
K.�mo b
r: Phone: License#
C to
F61 .G i. X79-o�aa.
Contact: Phone:
lbCupertino Business License#:
9LE A S �79�o7aa-
.Building Pemut Info:
Bldg. ❑ Elect Plumb ( Mech
" ,Job Description: 7—
Residential
Residential ri Commercial ❑
For Re idential In6 ilations:
r Attic M 1" floor 2nd floor❑ M
d6aere to min set back requirement 2( tf
r Commercial Installations:
tural calcs) ❑
Replacement same weight E] Additional weight (struc
Structural Calculations required for new ins' llation ❑
New installation Planning Approval Required
Cost of Project Type of C�lruFtion: Occupancygroup:
Strapped• On Platform Bonded Sq.Ft. Floor Area:
New Location R lacement
Qty. if
Applicablq Fee ID Fee Description Fee Grou
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL .
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BI2EMA:IRHALI A1C 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 —T—umbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING