03100016 (2) PITY OF CUPERTINO "° '?" �* vu �,,u
BUILDING DIVISION PERMIT kCONTRAC�IOR INFORMATION• m
a s�.teir�r,.t:
BUILDING ADDRESS: UNITED AIR COMFORT PERMIT NU03100016
OWNER'S NAME: 5819 N ANDREWS WAY PERMITLssuEDATE
TF.PT4F.N .7
NE, (408) 771-8967 SANITARY NO. CONTROL NO.
ARCHiTECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
!000 LICENSED CONTRACTOR'S DECLARATION Job DBSCriPIIOn
i U C 1 hereby affirm Ihet I am IittrLsed anter pm' rLt of Cha Icr 9 morning
w with Section 7")of D!,i.ion3ofthe Business a(essiu s e license /
ZLie fo-1 and fact. "i'>}RBIACE O/
Licenu 2 s.+ Contractor —�/
DOW C S meter
ARCHITECTS DECLARATION
1 undersand my plans shell he used as public records
t U
u0 Licensed Profcssionel
OWNER exempt fr DECLARATION
;0 0% 1 hereby reaso .("firm that 11. exempt from the Contractors Co License Law for me
.pO following reason. seroma RDLO Business and Profession Code;Any city it county
5 m which o9mres a e.also sea cores the alter,improve,demolish,or repair any ttmcture
_i< that heor its issnsed pursuant
nt to the thovisio s of for such Permit fiic a eig Law,
nenmcm
:a (hmhecricinnwit pSection7 the provisions of Ne ComnnLicense Law(Chapmry Sq. Ft. Floor Area Valuation
(eat he is xempth ionion1110d theOf basis f r the
NC Busalleged
xmpt Prorcaton.Any
Cade)or
that he is exempt Nemfmm end the baso far the alleged exemptlan.Any vlolmion of 34216082 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollen($500).
1,as owner.(,he property,or my..play.with wages as their mole compensate., T7��TT
will do One work.and die structure is no(manded or offered for sale(Sec.7064,Business CtIODS
— YfiS
and Professions Code:The Cn
msacme,Lt...Law does not apply th an owner or 3 0 3 - ROUGH M CHANT�AL
property who builds or improves Neuron,and who dos such work himself Orth ungh his
own employers,provided that such impowments are not intended eroffered formic.If. 304 — ROUGH ELECTRICAL
howeve,the building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of Moving Nat he did not build or improve for purpose of 505 - FINAL ELECTRICAL
sale.).
❑1,as owner of the property,am exclusively contracting with licensed conoapera to 507 - FINAL PLUMBING
construct the projen(Sec.7W,flusinees and Pofes.wes CWe:)no CoetfanNrf Lt. 508 — FINAL MECHANICAL
come Law docs not apply to an owner of property who builds or improves Neeson,end,
who cemmcts for Such projects with a contmetor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. .B 6 P C for Buts moon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Consent to seif-mature for WortrYs Compete
amino,as provided for by Section 37M of Ne Labor Code,for Ne performamc of the
work for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as myuired by Section
37 of Me Labor Code,for Ne performance of the work for which Npermit
is is issued.
My Worker'sCompensation lnnunnce,a rrics and Policy�ormrr •p.. p n
Cerro, sµra' AQ Y�, - Policy No.:; T" 1f 2 /
CERTIFICATE OF tlXBM PITON FROM WORKER$'
COMPENSATION INSURANCEC•6
(This auction need not M completed if the permit H fir one hundred dollen(S I00)
or less.)
I ccNfy that in the performance of No work for which this Permit is issued.I shall not
employ any person in any manner so as to became eubjecuo the Workcri Compensation „
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cede,you must
�O rorthwiN comply with such provisions or this Permit hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby ollirm Nat more is a centrontinn lending agency for the performance or
Yv 7 the work for which this permit Is issued(Sec.N97,Civ.C.)
y im Under's Name
2. vendors Address
Q I cerify urn 1 hew mad this application and slam that me above information is
]. H correct.1 agree to comply with all city and county ordinances and state law$misting to
V building convection,and hereby auNorim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to saw,indemnify and trap harmless the Cily of Cupertino spins,
fA liabilities.judgments,costs and expenses which may to anyway aamc againsueid Or
fow
APPLICAcnc NDEgonti of D WILL MPLY WITH ALL NO
NPOINT Issued by: Date
Re-roofs
Signature of ApplicanVContruNr af>¢ -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building Occupant store or handle hamrdous matetal
as defined by the Cu mo Municipal Code.Chapter 9.12,and the Health and Safety
Code.Seaton 25532(.)' All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Na
Will the epplio for'uvea buildingacupan(uucyvipmcnt or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it havardnuc ap'I'e 'nmts uJcfncdby the Day Arca Air Quality Management all new materials for inspection.
,arict?
❑Yea
1 have mad the he.rduuameoriels hoPoemcnts under Chapter 6.95 of Ne Cslirm.
nia Health&Safct ,Sections Z50 33andU 4.lundereundmuiOhi Wilding
Jars not caner ave e. a y respon lily o antfy the occupant of Ne
mgwrem tP ` r °L°`eep�t`yj Signature of Applicant Date
/o/,L,�_
Owner orauthorindagent spate All roof coverings to be Class"B" or better
10/02/2003 19: 22 5105303202 LEGALITIES INK PAGE 01
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CITY OF CUPERTIN0 North Bay Permit Service
FURNACE /AC v 3 a � 3988 Somerset Ave.
t "TY°PCa�str Iley;C 94546
cuPERrirvo P� Y2MIT APPLICATION FORM "
1
APN# Z 6 (� Date: l0 Z
Off .
Building Address: 2d
Owner's Name: ` Phone #:
ass - sR33
Contractor: License#: 75 7 S 9S
Cont act: Ph�703_ 2.653
4.
is
ApplicandCengactor: _ 1\ !Z_ +u�o S i 0,1>5 5/
Building Permit Info:
Bldi Plumb Mech
Job Description: G,,1O w DUU 13�U
Residential: Commercial:
Sq.Ft. Floor Area: S/Sq.Ft.:
,
Architect/Engineer: { Valuation: r
Type of Construction: ;' _ v Occupancy Group:
]icabl Fet; ID Fee Description Fee Group
1'
BREWURNI. Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRH A/C Units <= 10, 000 cfm MECHANICAL
BREMMISC? Misc Apparatus ELECTRICAL
1
EPERM Elec Pemlit Issuance ELECTRICAL
I Mech Permit Issuance MECHANICAL
PPERMITFEj Plumbing Permit Issue PLUMBING
BPERMFEEi ' Bldg Permit Fees BUILIDNG
BPLANCHI Plan Check Fee BUILIDNG
BUSLIC y. _Business License BUILIDNG