03090190 (2) CITY OF CUPEwrINO z>f+
BUILDING DlvlsloN PERMIT CONTRMJQRANFORMATION
BUILDING ADDRESS: PERMIT N00 3090190
l V
OWNER'S NAME: PERMIT ISSUE DATE
2003
)NE: SANITARY NO. CONTROL NO.
ARCHITECrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+oo LICENSED CONTRACTOR Orders DECLARATION
4ou F 1 hereby arum Inst 1-m licensed nna=r provisions of Chapter v(commencing Job Description
.26 with Se`,c,t�io�7")oCDivision 3 ofde sincas and Profession Code,and my license is
_ i<<^1 „u"derCt� a=.g REPLACE FURNACE & A/C
2t-W Date co CONTRACTOR: PACIFIC NORTHSTAR MECH.
A CHITECI'S U ATION
f z e understand mY plans shau M n µAs ."he rtrnw
J0U
Din Licensed Professional
S OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law fur the
00 following mason.enandoi ]1131.5,Business andimprove
ve dcsiom Codi Any city or county
<m which requires continue.permit re quires the pplic improv=,h Perm t t or repair any atrucmre
Z E y pnono its entedpurse pursuant
to the thovisio s O for sucContractor's
rile-sig w(stawmem
,to that he is licensed pursmnuothc provisions of the Conmaoh LimnY law(Chapter Sq. Ft. Floor Area I � BID "�'�'�
rt- (commencing with Section 7")of Division 3 of the B unnessand Pmfcssioas Cooky)ur v
Nal he is exempt Neafrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3WI92ghEh6er00
not more than five hundred dollars(g50B). - Occupancy Type _-
p 1,as owner of the pmpcny,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7W Business
and Professions Code:The Conuaetor'a Lt...law does or apply to an be,of gipft INC;7ectlon$
property who builds or improves thereon,and who does such work himself or through his 301 — ROUGH PliUMB
awn employees,provided that such impmsementsane not lnenlioroffered for sale.If. 303 - ROUGH MECHANICAL
however,the building or improvement is sold within one year of completion,the owner-
builder will have de burden of proving Nat W did not Wild or improve for purpose of 304 - ROUGH ELECTRICAL
sale.).
❑1,as wnR
er of the prorty,am exclusively contracting with licensed convectors to 505 — FINAL ELECTRICAL
o
construct the pmjm(sec.70a4,Business and Professions Code:)The Contractor's Lt. 507 — FINAL PLUMBING
=ettseLawdoesOutapplytoanownerofpropenywhoWBdaurimpm.rsNerenn,,ae. 508 - FINAL MECHANICAL
who contracts for such projects with a convactor(s)licensed pursuant to the Contocmr's
License Law.
El I am exempt under Sec. B&P C for this reason
Dwncr Dare
WORKER'S COMPENSATION DECLARATION
1 hereby AIR.unser penalty of perjury one of No following tlecuralinns:
1 hoe and will maintain a certifie.w of Conum w sclbinsum unworkcrscump=n-
73700ofth
on,as provided for by Section 37W of Ne labor Code.for the performance of the
k for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
LaborCode.for Ne Performance of Ne work for which this permit is issued.
Work 's Compcmation uoon =tYnurame
CERTIFICATE OFXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed drive permit is for one hundred dollars(SIR))
or Icsa.)
1 unify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as In Wcumc subject..the Wm1xclA Cmd,m dmd
Laws of California.Date
Applicant -
NOTICE TO APPLICANT:Ir.after making Nis Certificate of Exemption.you should
become subject to the Workers Compensation provisions of the labor Code,you most
]Z forthwith comply with such provisions or this permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby Affirm that Nem is a constmclinn lending agency tot the performance of
X Ne work of which this pcmtit is issued(Sec.3097,Civ.C.)
ALender's Name
ZI Z Lender's Address
J Q 1 unify Nat 1 have read this application and suite that the above Ofonnatiun is
{ (— cotrtn.1&&Me to comply wit all city and county on inances and state laws relating to
U building comtruction,and hereby-utbm onrepresentatives of this city to enter upon the
anovcmemiunctl propertycosts
for and,
cdes purposes.
(We)-gone t"save,indemnify and keep harmleu the City of Cupertino against
Z
liabilities
judgments,meats.costs and expo res which may in any way aecrve against said city
;J z or he graining oft permit.
ULDTION ERST NDS D W L COMPLY WITH LL NON-POINT Issued by: Date
plicanVContrmtur Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
applicant or future building occupant store or handle hazardous material
the Cupertino Municipal Code.Charder 9.13,and de,Hcalth Add Safety
5532(a)f eft All roofs shall be inspected priorto any roofing material being installed.
Will the applicant or future building Occupant use equipment ordcNccs which If a roof is installed without first obtaining an inspection, I agree to remove
iI hazardous air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
viet?
❑Yea COP
I have read the WAMI-s mawnxls acquirements under Chapter&. 5 of the Califor-
niaflGalN&SofetyCode,Satium ZSXI5.25533 am12553q.l undersand Nuir Ne Wilding
Jouuui(n,.ot c ally ban a..at Nat u my responsibility w andfy a pant of the
at hot At pd issuance afa Conrad,of IXcu cy.
[7� Signature of Applicant Date
0.be,m the ducal Da1C All roof coverings to be Class "B"or better
r
CITY OF CUPERTINO U 3 0 o ( � v
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# 72- Date:
Building Addres . -
O ner's Name: P ne#:
z S
ontractor: ,, ^^ Phone: License#:
�' iC (Z S A &, - (7'1.
C�ct: Phone: Cupertino Business License#:
6-68 -
Building
-Building Permit Info: ��rr
Bldg ❑ Ele PlumMec
Job Description: 5 �, ,1 �
Residential 1q, Commercial ❑
For Residential Installations:
Attic ❑ 151 floor ❑ 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 insta11 ti n Plannin Approval Required El
Cost of Pro' Type of Const t : Occupanc group:
Strapped PlA$km ❑ Bonded Sq.Ft. Floor Area:
New Location ❑ Re laceme
Qty. if
Ali le Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN MC Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMII'FEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING