03090196 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �'tGQNTRAGT R INFORMATION S
BUILDING ADDRESS: PERMIT'003 0 90 196
a OWNER'S NAME: PERMITISSUEDATE
CASA DE ANZA HOA 09/24/2003
ONE: SANITARY NO, CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±00 LICENSED CONTRACTOR'S DECLARATION
I U I hereby affirm Nal I am licensed under provisions or Chapter 9(commc..eg Job Description
a�i with Semion]Dnp of DiviaionJof ere Basin end Prufessiom Code.end mylicens is nn
.Orn Infairora neer 1111 q 7 REP CE FIURNAP & ASC
y 2 Licens I Lic.
;moo Dam con CO� CTOR-%�PAIC NORTHSTAR MECH.
As Shall x Ma D A ATION
I undcesmnd my plans shall M cud as public records
E�U r[[h41111 I J
ya Licensed Professional
OWNER-BUILDER DECLARATION
0 0 I booby,('Bens o n71 1. exempt from the Contra,Co License Lew for the
O O (which requires
a.(Sadao]orsor i.a1mr, and improve,
de ions Cmlc:Any city ter county
m which myuires a pcnnit m cnnswn,clmL improve,ecmnlish,ter repair any structure
\M Zl0
prior In its issuance,also rcquiror the applicant nor such Permit file a signed statement
ez< that he is licensed fondant bthe ProviainMOfthe Contncmr'sLittnscLaw(Chapter 9 Sq. Ft. Floor Area Valuat"777
1. (commencing with Section 7")of Division]of the B usiness and professions COO)our
3r$ Nat he is eaempt etenfrom and the basis for the alleged esemption.Any violation of
Section 7071.5 by any applicant for a permit ubjects the appliesnno a civil penalty of 3��R25[ilRlber0 0 "/ Occupancy Type
not mart man h
five yndmd dollars($500). - - - - - P Y ---- -
❑ I,asowncr ofthe pmpeny,ormyemployces with wages as theirsolecompenation,
will do the work.and the swctum is not immmdedoroffered forule(Sec.7014,Business J1J,j' ]It$p�
and Profusion.Code:The Contractors License Law does not apply men owner of 3 01 — ROUGH ft V lv1t511VCi ctlons
property who build&or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered forsale.If, 303 — ROUGH MECHANICAL
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden or proving Nat he did not Wild or improve for purpose of 304 - ROUGH ELECTRICAL
"le')' 505 - FINAL ELECTRICAL
01,as owner of the property,am exclusively contracting with licensed convectors to 507 - FINAL PLUMBING
construct the project(Sec.7014,Business and Formulas Code:)The Contractor's Lt
cons,Law does not apply in an owner of property who Wilds of improves meson,and 508 - FINAL MECHANICAL
who eomneta for such projects with a,oro smr(s)licensed pennant o the Contractor's
License law.
❑1 nn escmpt under Sec. ,B&P C forthis mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby amen under penalty of perjury ane of the fallowing declarations:
1 have and will trainee.a CeriOcme of Consent to set 6imum for Wmker's Compo.
1371W
on,as provided for by Section 37M of the Labor Code.for the performance of the
k for which this permit is inured.
I have and will maintain Worker's Compensation Imuran¢,as required by section
of me laWr Cade,for the performnce of the work for which this permil is iasued,
Worke�omnsatioo�mmum carrier and Policy number artitA
CER, IFIC
COMPENSATION
O WORKERS'
NSATIONINSURANCB ,
(This section need not W completed HIlse pcmdl H far one hune ed dollen($I())
or lea,)
I ccnlry that in the perrormance of the work for which this permit is issued,I shall nut
employ any person in any manner an as In become subject to the Workers'Compensallan
Law.of Cal ironies.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis CeniRcem of Exemption,you should
become subject 19 the Workers Compensation previsions of the Labor Codc.you must
�z forthwith comply with Such Provisions orOisPermit shall the deemed rooked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby alarm that them is a eomtruction lending agency lot the perfurmance or
Y, the work for which this permit is issued(Sec.30)7,Civ.C.)
Y0 Lenecr's Name
= z tondo's Address
J Q 1 cenify that 1 have read this application and state that the above information is
Fcancer.1 agree to comply with all city and county uNinances and Stam laws misting to
C.1 building convection,and hereby authaflne mprescromms of this city to enter upon Oc
J+a abnvomemiunee property for inspection purposes.
(We)agree to Save,indemnify and keep harmless the City or Cupcniao against
y IiatuRICS.judgmcnu.cosu and expenses which may in any way accrue against said City
in eonsequ c of the grami of thit=i��;DD.tc APPLIC UNDERST DS AN-POINT Issued by: Date
C ENgRe-roofs
area fAppliam1 onmcmr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building Occupant atone or handle havareous manorial
as no by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Sc❑clYear:sSJz(a)7 Na 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
h hazardous air contaminants as darned by the Day Area Air Quality Managcmcm all new materials for inspection.
atria? .aT�
El Yes Cl rvtr .
I have rtW the W7armmsmaterials rtyuimmenu under Chapwr6.95 clone C.lifoa
iia Halm&SafctyCode Sstions25 5.W33sed25534.1midesunddhatirdbe wilding
does not a ntly hew a SOL thus is my responsibility in nOury the necomal of me
fcqume w is uta mdpn inissaaneear.cemBeatanraapan,y. Signature of Applicant Date
one ,u,h ,reagent Dam All roof coverings to be Class "B" or better
CITY OF CUPERTINO 6
FURNACE/AC
CUPEF OF
PERMIT APPLICATION FORM
APN# / 2 �� Date:
Building Address:
Owner's Name: Phone#:
S a D15 Aduzog .S 0 2
C tractor: Phone: License#:
o 5-1A Meck 56 6 - o ma o 0
Cont t: Phone: Cupertino Business License#:
gz
56 -oma
Building Permit Info:
Bldg ❑ Ele Plum Mech �]
Job Description: fi
Residential ❑ Commercl ❑
For Residential I Mations:
Attic u 1" floor Ll 2nd floor❑
' Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Warming Approval Required
Cost of Projec Type of C66-! c Occup y gr
i
Strapped ❑ P tf 13Bonded Sq.Ft. oor ea:
New Location 11Re lace
Qty. i ,
ApplValqFee 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 Seismic Fee Res BUILDING
EPERMlTFEE 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
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