03090187 (2) `: CITY OF CUPEWFINO r^",3w to ,e^-err• �"`` �'"" `
o BUILDING DIVISION MIT CQNTRACTQRIINF6RMATIONN *,.
BUILDING ADDRESS: PERMIT N003 0 90 18 7
n4F;r MARY A172 A
OWNER'S NAME: PERMITISSUE DATE
CASA DE ANZA03
NE: SANITARY NO. CONTROL NO,
ARCHIT11=1INGINEER: BUILDING PERMIT INFO
BLDG ELECF PLUMB MEC14
0 0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION Job Description
U F I thereby from Out I am escrP
licensed under provision of Chapter 9(commencing
with Section )of Division 3of the Busincuand Professions Code.and my license is
�nZin mu mate of `1-0 r7 REPLACE FURNACE & A/C
License Cl s =C.On_
t Deu Comm
As.hall CTS DEC ATION
f
understand my PlanseMll be used uhlic ro m
dyU
o LiccnscJ Pm(cssianal
OWNER-BUILDER DECLARATION
0I 1 hereby.('Sere that I I exempt from the Contractor'. :Any c Lew for the
p O following remnm.(Section]Iy3.5,Business and improve.
dieiau Calc:Any city a county
5$ which rtquiru issuance.Pewit to rnneste, also improve,h Permit t nr repair any uncture
thiormiuensedpalsorequithe the, forthe such PcwiOaicensle ae ned aw(Ch cmcm
p (commencingwJpursuannolheofDivismnftheConuinessandProflsw(sCapmr9 Sq. Ft. Floor Area Valuation
Eq s❑$ Oat he is
(commencingwith ]0110)the Division rOf the egad Business And on.Any i lotionade)oro 7 rl 3,2'6:5 07.5--. 0
3� Nat he is exempt Nemfmm and the heals for On alleged exemption.Any violation of - �ht � 2r 0,
7.5
7031.5 by a"applicant for,Forrit subjects the applicant to a civil penalty a, I APN Number' ( Occupancy Type
nut more Nan Bw hundred dollars($500). _� - P Y -— -
❑I,as awner of the pmpeny,or my employee'
wiN wagesu role compcnsatlnn,
will do the woh,endde structure is not imendcdorofferedfon (Sec." Seined
and Professions Code:The Conlracmr's License Law disc no ply1o'n���a��yyJJ'ner r'1 ns
prapeny who builds orimprovcs thereon,and who doe'suchwor Mbujh hl 03 DUt:PG L
awn cmployect provided that such improwmmut arc not intended oroRered for role.If. 04 L'CTRI CAL
however.the building or improvement is sold within one year olcompletion.Ne owner-
builder will have Ne burden of proving that he did not build or imv profor purpose of 505 - F I NAL ELECTRICAL
s1, 507 - FINAL PLUMBING
❑consu asOwnerthe pmfthe Sec.7 ,,am exclusively crowning with licensed Cour a¢mrs to 508 - FINAL MECHANICAL
M.La the project(Sec.]0x4, .a,of and Professions whoei Cade:)The.the
mr's nd
M.Taw don raupply tu an owner of tractor(who builds ar improve thereon,and
who contracts for uch projects with a eonweroK0licensed pursuant no Um Conuactor''
License Law.
❑tem exempt under Sec. ,SkPC far this moon
Owner Date
73011WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penally of perjury one of the following declarations:
I have and will maintain a CenlOcate ofConsem to self-insure for Worker's Compen- -
M
on,as provided for by Section 37M of the Labor Cade,for the performance of the
k for which this permit is issued. _
1 have and will maintain Wmkesi Compensation Insurance,as mouired by Sactian
ofdu Labor Code,for Ne performance of Ne wish far which thin pctmit is issued.
Workeer'',C�om�peensatioonn Instar ce artier radPalirynum �1ricr:e,]7P is—T_f Policy No.:f, Cd/
CERTI•ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not heeompleted I(the permit is franc hundred dollar(SIM)
or les..)
1 certify Out in the performance of the work fur which this Permit is issued.l.hall not
employ any person in any manners.as In Mame subject to the Workers'Compe...lu.
Laws of California.Date
ApPlica,
NOTICE TO APPLICANT:If.after making this Ceniricate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
Oforthwith comply with such provisions or this Permit shell W deemed revoked.
ti CONSTRUCTION LENDING AGENCY
1 hcmhy,affirm Nat Nem is a construction lending agency for de Performance of
Y, „> the work for which this permit Is issued(See.3097,Civ.C.)
lender's Name
Lender's Adtlress
;J p 1 and(that 1 have read thI+aPPIleallon W elate that the above information is
y ^ torten,l allose to comply with all city and county owinances and sou laws rtlating to
SV' building construction,and hcmhy AuOOAM mprtxnmivol of this city to enter upon the
4 above-mentioned properly for inspection purposes.
(We)Agree to save,indemnify and keep lurmless the City of Cupcnino against
:r to Iiebilities,judgmenu,costs and expense which may in any way acema against said City
J ',[� inconsequence Ithe Braining flhis Permit.
APPLICANT NDERSTA S AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SO RCE R TI
Re-roofs
gnaw o P HAZARDOUS OUS MATERIALS DISCLOSURE nViCorommor Dau Type of Roof
II Ne applicant ar future Wilding Occupant store or handle harardous materiel
as f ed by Ne Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
.Seth..15531()? All roofs shall be inspected prior to an roofing material bei.
❑Ye' ❑Na P P Y g g installed.
Will the Applicant or more building rapant a equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
It havardnm air conuminanu as dcrincd by the Say Area Air Quality Management all new materials For inspection.
OmcR
❑Yes ON.
IIIaw m W the hznNausmaerialsmquimmenu under Choper 6.95 of the Califne.
nie HcoIN&SNcty Code,Sec6.m 2]705,15533 and 25534.1 un@rsmnd Netif the Wilding
Jura no w ly how a moot,NeI'I is my msporuihitoy a roof,the on.,Of Ne
require h h map' uissu eef.ceninne.roccurneey. Signature of Applicant Dale
to4n u authori ulagent D„e All roof coverings to be Class nBu or better
CITY OF CUPERTINO
FURNACE/AC 3 `' ° ( 8 7
CUPEI�TINO PERMIT APPLICATION FORM
APN# Z� Date:
Building Address:
`16 's- rell f,
Owner's Name; Phone#:
Z U 0 �
Co actor: Phone: License##:
a Q Q Gr Mo C 20 11
Contact: Phone:, Cupertino Business License#:
Building Permit Info:
Bldg ❑ Ele ` Plumb Mech
Job Description:
Residential ❑ Co ercial ❑
For Reo�eidential I llations:
Attic LJ 161 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 install 'on Planning Approval Required
Cost of ct: Type of Cons truc n Occup cy gr p:
Strapped n at rn 0 Bonded U Sq.Ft. a:
New Location ❑ Replacement ❑
Qty. if
A lic le 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 Seismic Fee Res BUILDING
EPERMITFEE 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 n I BUILDING
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