03090189 (2) CITY OF CUPERTINO €�. , :5
BUILDING DIVISION PERMITCONTRACT(IR(INFORMATION
as#�v"',: '+ >.asF::hs £hL,•�.:5,�wunis '• ,"-,ry
OVI LDING ADDRESS: PERMIT N003 0 9 0 18 9
a
0 NER'AAA. t--' \�� �'�. `/ �� �1 \, �.. Y RMIT ISSUE DATE
DE ANZA HOAU 2003
L
NITARY NO. CONTROL NO.
ARCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ICENSED CONTRACTORS DECLARATION
irm that I am licensed under provisions of Chapter 9(commencing Job Description
Zoa with fDivision 3ofthcposinccs and Pr"fessiom Code.and my license is
in futc �Y g)nK LceJ4 CREPLACE FURNACE & A/C
°� -0.? CONTRACTOR: PACIFIC NORTHSTAR MECH.
8 ARCHITECTS RATION
Ecu I understand my plans shall M used as public records i
_per Licensed Pmfcssienal
Oat I am exempt
from
DECLARATION
a y I hereby affirm up 1 1. cxcmpt!rum the Contractor's License Law for the
<00 following notice. sermon toast Business and Professions Code:Any city or county
m te+ which requsa a Permit re construe,alter,improve,demolish.one pair any tvument
uZr Pnonn its issuance,also requires the applicant for such permit to Olcasigned statement
aso that he is licensed pursuant lathepmvisionsoftheConvactor''sLiceas,Uw(Chapter9 Sq. Ft. Floor Area Value
rt- e
(comm ting wi th Section 70M)of Division J of the Business and Professions Castle)or
S that he is exempt Ibacterium and the basis for the alleged exemption.Any violation of
Section 9071.5 by any applicant for a Permit subjects the applicant to a civil penally of
not32�IBH�En6er00
mnmthanr hundreddolu..D5B0). .___ Occupancy Type __-
❑ Lazawna of the pmpcny,onmycmplended wiNwagautht, selccompBusincn,
will Pr fework.and Ne o Com is ,kens Lea, ilddo permit,WE apply toad,owner
of
es
and lrLywh obu Code:The improves
teeem,License Law docs not apply to an owner of 3 01 - ROUGH Y�U1Vli 11V T,j GLIOfIS
own employees.
who builds orimprovesthcrcon,andwho rdoes am not such work himselfor edtformic his
however,the
thnt svehemprnvemwuercnet eats ofdoardetied formic, . 303 — ROUGH MECHANICAL
haw co the building or improvement is sold within one year of completion.theowner-
buildef will have the burden of proving WE he did not build of improve for purpose,of 304 — ROUGH ELECTRICAL
salt.).
Q1.as owner of Ne property.am exclusively contracting with licensed convectors to 505 - FINAL ELECTRICAL
construct the project(See.nua.Business and Professions Code:)The Cmvasrdr's Li- 507 — FINAL PLUMBING
ease law does not appy m an Owner ofpmperty who builds or improves themon.and 508 - FINAL MECHANICAL
who contracttt
s for such projects with a contractors)licensed pursuant the Convector's
License Law.
El I ren aempt under Sec. ,B&P C It1his mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of Ne following declarations:
1 bras and will maintain a CeniOcme or Consent to xlf-insum for WurkersCompen-
IC1371M
on,az provided for by Section 37M of the Wer Code,for the rcrfonnance of the
k for which this permit is issued.
1 have and will maintain Worker.Compensation Insurance,as required by Section
of the Libor Code.forthe performance ofk far which this pertnit is issued.
sWor cls Collm��rcm�aation�m`wrenLT/,carticr an olicy number art:
. 51L4/e /'a4yn olic,No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or less.)(This section need not M completed Ell rcrmll is for one hundred dollars(S IME
1 cenify Nal in the per4mnance of the work for which this Permit is issued,I shall not
employ any NOW in any manner x as to Mrome subject to the Worker.Compensation
Laws of California.Oats
Applicant
NOTICE TO APPLICANT:If,after making this Ccniflar,of Exemption,you should
become object 19 the Worker.CompLensation provisions of the ehor Code,you must
Oforthwith comply with such provisions or this permit shall he deemed revoked.
Z (n CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a cmauuelinn lending agency for the Performance of
L' the walk fur which Nis permit is issued(Sec.JPBt.Civ.C.)
Llender's Name
Zy z lender's Address
,J Q 1 certify Nat I have read this application and Ethic that the above information is
L mmpcl.I egree to comply with all city and county oNinancce and store laws relating to
7 V building consweion,and hereby authorim EaPrescnmives of this city to enter upon the
a. Wahgvc-mcmiuncd Property ref pection ich
y CL (We)agme to an.•interior fy and keep harmless the City of Cupertino against
t,, liabilitin,judgments.costs no cePcrEscwhich
ma
s which mey in any way accuse against mid City
J,'Z m consequence of Ne gran' g of Ih' Per it.
.. ADPLICA CE GUND R OS D ILL COMPLY WITH ALL N-POINT Issued by: Date
Itasca of AppicanUContracmrDem Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(Mubuilding occupant scare or handle doua material
az fined by the Cupertino Municipal
cipal Code,Chapter 9.12,and @Ha.c Health and Safety
de,Section 355J21a)?
❑Yea alpIq 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
I luminous air contaminants m Echoed by the Bay Arca Air Quality Management all new materials for inspection.
strict?
Yes 0%R
Ihavere thchisento smaamialsmquimmcnsundcr Chaptcr6.950fthcCalifor-
al.HealthGS Cats,Sea 25YE 255JJmd]SSJd.l understand thatifthe building
docs not ed he a testa thi my rnpmde aibility m notify Excitant of the
require ich Ipus do ixx. Of.0 the aeupancy.
Signature of Applicant Date
Own or named agent D,re All roof coverings to be Class "B" or better
i
' CITY OF CUPERTINO
' dJ FURNACE/ACCITY Of
CUPERTINO PERMIT APPLICATION FORM
APN# — Date:
Building Address �
NL.
Owner's Name: Phone#:
z 5Gvi- 0�L
C ntractor: Phone: License#:
p 1J 2 a S6 - U�0' Lip
Contact: Phone: Cupertino Business License#:
J - 67-91
Building Permit Info:
Bldg ❑ Elec Plum ech"OS�
Job Description:
C—
Residenti mmercial
For Residential Installations:
• Attic ❑ Vt 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 installation Planning Approval ggqyired ❑
Cost of Proj pe of Cons i Occup cy gr
Strapped ❑ n atfo Bond'ed LZ Sq.Ft. Floor Area:
New Location ❑ Re lacemen<
Qty. if
A lic e Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BEMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING