03090188 (2) CITY OF CUPER'rINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
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BUILDING ADDRESS: """"03090188
ERMIT N00 3 0 9 018 8
1
OWNER'S NAME: PERMIT ISSUE DATE
)NE: SANITARY NO. CONTROL,NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELF.Cf PLEUMB MECH
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i00 LICENSED CONIRACIUR'S DECLARATION
I F 1 hereby affirm ]Ob Description that I am licensed under provisions of Chapter 9(commencing
W with Section 7WOlsf Division S of Nc Business ufcxvinm Cudc dmy head.is
'� r"in fuB` °c�� u _ � REPLACE FURNACE & A/C
alaz " Lic.X
Dow
RCHITETSD ATION r JCd Skil' CONTRACTOR: PACIFIC NORTHSTAR MECH.
f z 1 underxanJ my plans shall he used as public records
)yU
° m
Licensed Professional
g
OWNER exempt
DECLARATION
0 I hereby aso mGnm that I am excmne!rate the Comranm'a Code:Any c law for the
p O following rcuaa(Section IIP stn Business andimprove.
Professions h.orAny city s county
m which its requires a Perme.also
bi mrax the alcor,nt for su h Permit t or a pair any structure
-iy pnonnisissmncc.aluant to the
the applicant for Contractor
License ned Law(Chapter
eZO that he(commencing
cinglice wJpursuion71D egmviviomnfthe CommnessancenxlaonsCodmr9 Sq. Ft. Floor Area Valua[4fryl7'7'7
2� (est he is xemptb Serefth.Il t nl bussisof r the
theBusiness
exempt Professions Code)or
Nal Section
is 31.5 b Nem from and Ne bur for the alleged applicant
to Any violation of
not io re than
6y arty red dolt for a lars
(SSPermit subjecs the applicam to a civil Penalty of 3 2 F1512O t�er0 0 Occupane Type
not more Nan f hundred dollars(5500). '
0 1,as owner of the property.a my employees with wages as their Solt compensation,
will do Ne work.and me structure is not intended or offered for Sale(Sec.1064,Business
and Profusions Code:The Convene:License Law docs not apply to an owner ofq ctions
ow
progeny who builds or improves thre
aon,and who doessuch work himselfor through his 301 - ROUGH P Ulv1B INCA
m cmployae pmvidcd that such improvements are not intended or offered formic.It.
however,mtir ,303 - ROUGH MECHANICAL
e building or improvement Sold within enc year of completion,the owne
builder will have the burden of proving that he did not wild or improve for purpose of 304 - ROUGH ELECTRICAL /
Ell.. 505 - FINAL ELECTRICAL
❑ 1, i owner of the So .7C4,,B exclusivelynd convening Cid:)cueCcontnnors i.
Constrict mepmktapplyoanownsmessand ProfessionsCode:)orr ThcC thecton.u. SO'I - FINAL PLUMBING
cense lzwdworsuchplyma with
orcropenywho
censeddursimprovaContra)and 508 - FINAL MECHANICAL
who
ns contracts for such projects with a conmaar(s)licensed pursuant a the Contractor
License law.
I am exempt under Sec. ,B&PC for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Consent m Self-insure for Worker's Compete
cion,u provided for by Section 37W of the Labor Code,for She performance of the
work far which this Penmil is issued.
0 I bare add will maintain Worker's Compensation Insurance,u required by Section
37W of the Labor Code,for the Performance of the work for which this Farm it is issued.
Mpyyrker's Compensation Innsumndg carrier and Policy mamba(am:
4_DRr/er: '�i�Yt. �P !IJ aYl Poo No.: T6I
CERTIFI ATE)F EXEM ON M014 WS'
COMPENSATION INSURANCE
or less.)(This Section need not be completemi
d if the Pert is for one hundred dollars(SI W)
I cenify that in the performance or the work for which this Permit is issued,I shall not
employ any pain in any manner an u or become subject to the workers Compensation
Laws of California.Data
APPlicant
NOTICE TO APPLICANT:If,after making this Ca mpeau of Exemption,you should
become subject to the workers Compensation previsions of me Labor crude.you must
� ,Z fonhwi lb Comply with such Provisions Or this Permit shall he deemed revoked.
zO CONSfRUMON LENDING AGENCY
1 hereby atDrn mat mere is o construction lending agency lot me Performance of
L'ti the work for which this Permit is issued(See.300,Civ.C.)
1 Landcf's Name
z Lender's Address
';J Q 1 cenify that 1 have read this agplication and ream that he above information is -
i F, coral.I agree to comply with all city and County ordinances and state laws relating to
U building construetion,and hereby authonre representatives of this City to enter upon the
Lk1 awvcties judgments.
dgmgcr (Of inspection pourpwhich ar-
may
a
ti p, (We)agree m save,indemnify and keep harmless the City of Cupertinv against
N incoitia,judgmctoss endapeues whichmayin any way accmc against Said City
J'Z in�"nuq"ene mfib egranting"flhispermil.
APPLICA UNDERST DS A D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R ULATION .
gftfiby
ppli I/Crooncm Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
applicant or future building Occupant store or handle havardmus material
e Cupenino Municipal Code.Chap.,9.12,and me Health and Safny
oriss3xan two All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building reentrant use equipment If a roof is installed without first obtaining an inspection, I agree to remove
rap s p y pmcm or devices which g
ld�
t hazardus air contaminants u refined by the Bay Area Air Quality Management all new materials for inspection.
.trict?O YceI have read the hazardous materials requiremens under Chapter 6.95 of dte Calif r,
Health&SafelyCode,Satium35X15.3553]and255}.I undersovw Lha if de wilding
wt curtcnlly haw a anL Ws r my respouih;litY m no:fy the oceupant of the
uirtmens w ich usl met pA n issuance ofa Ceni:cam of Occugancy. Signature of Applicant Date
ne ra 9rivnragt.t Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
� FURNACE/AC o3
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
i
Building Addre s:
Owner's Name. /J Phone#:
yg 0 P— IUZ ri S-6 ° -a2
61!7-
Ctractor: Phone: License#:
�,Q eR s' P�� S66 -a� C � p q 'l
Contact: Phone: Cupertino Business License#:
5G? - ung
Building Permit Info:
Bldg ❑ Elect Plu Meclp
Job Description:
1421
Residential ❑ Co rcial ❑
For Residential Installations:
• Attic ❑ 15` floor ❑ 2"d floor❑
Adhere to min set back requirement[]
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New install atioyj Plannin A rov uired ❑
Cost of Proj pe of Construction: Occupancy roup:
Strapped P tf ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
A 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 A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE 5Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING