04110043 (2) CITY OF CUPERTINO -• - e/�+ 'vas,
.BUILDING DIVISIONPERMIT *+ 431'{"C1R � � 1�•
_
BUILDING ADDRESS: - PERMIT NO
RESIDENTIAL HEATING AND A/ IN 04110043 '
•.A - PERMIT ISSUE DATE _
.c'
ON m .:. - - SANITARY OLNo. -_
ARCHITECT/ENGINEER: BUILDING PERMIT INFO"'
.. .; .. _
ELECT PLUMB MECH '
LOo LICENSED CONTRACTORS DECLARATION Job- -
1 em 1, affirm that 1 em licemcd under pro ai ;or Can, 9(commenting IOb DOSCrIpt100
with Seco hNDivtxlan Sof the BuuneuandP ssiunaC de,end mylicenx s _
m full fo d effect.
Licenul anti o Lica I�FJPLACE HVAC _ Zv
Dem Comrac,or -• ^9
q�q ARCHITECT"DER
'Ky eZ -hxdmY plans shall be usedas PUM1L m La tnC.
-
n
3 Licensed Pmfcanionel
OWNER-BUILDER DECLARATION -
E 1 hereby affirm met 1 am exempt from the Chancier.License Law for the _ / J -
i p O follnwmg mann.(Section](131.5,Bminms and Rvfcssinns Code My city m county
x$ which requires.permit to construct,alma improv,demnlivh,or repair any aBucmm -
��y prior to its issuume,alar requlrm mcapplimnt for such Permit m file.signed statement "
e that he is licensed pursuant to me previsions of theContrutor'sLcenselaw(Chapter9 , Sq..Ft.FloorArea Valla '..r
els a (commencing with Section 7")of Division 3 of the Busbous and Prorhad Cnde)or ... ;
that he Is exempt members and me amu far the alleged exemption.Any viohllon of
Section 7031.5 by any applicant for a penult subjects the applicant to a civil penalty of _Q�r �yrp�e " Occupancy Type -
net mum man 0w hundred dollars(5500). 3`.J fi V O V Z%. U 0
❑F;mowncrafthe proprny,mmy employers wire wagesm Heir axle rompenaddon,
will do the work.and the an.tum is natimmnded aroRemd forssfe(Sec.7044,Businms Re(hi)red Inspections
and'Professions Code:The Commcmrs License Law does not apply m an owner of +." ,
- . • 'property who bulldsor improvm seerson,andwhodoea such wahhimselfor through his
e - 4'
.we employees,provided mat such improvements are notimmadetl tampered for sale.If, -
however,die building or improvement is sold within one year of compledon,me owner
builder will have the burden of proving mat M did not Guild or improve for purpose of _
ssm.).
❑1,as owner of me property,am exclusively contracting with licensed contractors,to
canalroa me project(Sec.7044,Business and Professions Code:)The Contractor's Li.
came Law docs not apply to an owner of property who builds or improver thereon.and _ - -
whocontracts(or such projects wim acomrecter(s)licensed pursue.,to the Contractors- --
License Law.
❑Iamexemptunder Sec ,BQPCfm0nsmaon , .
Owns ---- Data
WORKER'S COMPENSATION DECLARATION
I hereby afftn under penalty of perjury one of me following decimations:,
I ham and will maintain a Certificate of Consent to self-insure for Workers Compen- - -
th n.as provided for by Secuon 37M of the labor Code,for the perfam uce of me
work far which this permit is banned.
❑.I have and will maintain Worker's Compensation Insurance,m required by Section _
3]00afinefabar Code.for me performance of me work Turn ' permnisissued.
M We
Compensation Insurance.artier end Policy no r CC^^ .a t
' C .S Tlit l LV\-d Policy No.:-Ow�vs� "a .,.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not bccomple ed tithe permit is rarombundmddoiam(SIM) .. "
or lam.)
I certify met in to performance of the work for which this permit is issued.I shall not -
employ any person in any manner so as in become subject to me Wod ed Compensation -
Lem of California.Data
AppII.L ,
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should -
become subject to the Workers Compensation previsions of the Labor Code,you must
Z 'forthwith comply with such provisions or this permit shall he deemed revoked.
zCONSTRUCTION LENDING AGENCY
(r I hereby affirm that them is a construction lending agemy forme performance of _ -
y t>s the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lenders Name
=z Lenders Addrem
V 0 1 certify that 1 have mad this application and mm met ma above information is
U,Fcorrect.lag=to comply with all city and coumy ordinances and sum laws miming to
O V building construction,and hereby authomempmmnmtivesofthis city toenter upon the
W above-m unioned property for impaction purpasea.
(We)agree to save,indemnify and keep harmless;the City of Cupertino against /
faA liabilities,judgments,costs and expenses which may in anyway accrue against said City
V Z in comcquence of the granting ofthis permit. „
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU C RE ULATIONS. -'•`'
t Re-roofs
Si tare of Applican✓Conuclor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W ill the applicant or future building occupant store or handle hmardous mamdal
u ticftnad by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CWe,Sec❑tionYm o 25532(01 All roofs shall be inspected prior to any roofing material being installed.
N
will the appliant nr mum baRaing oc.npant vs,.equipment or devices which All
a roof is installed without first obtaining an inspection,I agree to remove ' -it hanrdnus air conuminanu m JeOned by me Bay Arca air Quality Management all new materials for inspection.
iatric,?
' ❑Yes No
Ill 11 mad thehmaNn smamrialsrequiremcnts under .Chapter fi.YS afthc Califnr
nia Hul h4 Safety Code,Secuom 255()5,25533 md25534.1 undentW thmifmc building
dans not comedy haw a talent,met it u my responsibility m notify me occupant of the
mquirem vwhichmustbcmet prior toiesuxnceare rtiE.amofOccnpmncy. Signature of Applicant Date
er or aamnavaa sg.m oat. - All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
a0lo
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADRRE S: PERMIT #
�/ V ism
OWNER'S NAME: �r� lt- 1 S PHO # (ttoro� -1-
GENERAL CONTRACTOR: C a \� 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
HeatingQSn ti al ti i c OSS S
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
0 e /Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
UPERTINO PERMIT APPLICATION FORM
APN # Date:
6 l` 1Qq Nov. 16
Building Address:
l p--1 l l-�
Own is Name: Ph e #:
I ten+ � 1c_r �ovqe aG
Contr tor: Phone: License#:
+ d � n4i �i l�nG 21-1-Lio tic
Contact: Pone: Cupertino Business License #:
e S41- n 311- � to13
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential X Commercial ❑
For Residential Installations:
Attic ❑ 1"floor ❑ 2"d floor�
dhere to min set back requirement❑
Ivor Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New Inst ation Planning ApproygkRaquired ❑
Cost of ect: nom, Type of Construe ' Occupancy group:
Strapped ❑ On Platform LJ Bonded Sq.Ft. Floor Area:
New Location ❑ Re lacem nt
1'cab a Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE I Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITTEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License . BUMD/ING