04120133 (2) CITY OF CUPERTINO
BUILDING DIVISIONPERNUTGONTRACTOR INFORMATION
M
BUILDING ADDRESS: SCHAUMANN AIR CONDITIONING PERMITND04120133
1092 MILKY WY
OWNER'S NAME: PERMIT ISSUE DATE
DONNA MASHTARE HEATING & PLUMBING T�iC 1C)4
ONE: SANITARY NO. CONTROL NO.
(800) 986-0133
. . ARCHITEC17ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
L O o LICENSED CONTRACTOR'S DECLARATION
u I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Se
ction 7000)of Dhakon 3 of the Bu li cn and Rofessimu Code.and my license is
rd thfull forces nd «cq. WATER HEATER REPLACEMENT
j q Z License Class y�' Lk.a
i_a Date /2-/•7..a f�Cunrecm�T`'vtJMGC
"i ARCHnECPS DECLARATION
yyp�7 I undersand my plans shall be used as Public rtetrcds -7
zlyU
3;'t; Licensed PNfead...I � /^•
5 OWNER-BUILDER DECLARATIONS/)\I
. i Y 1 hemhy.IErm that 1 em exempt from the C.Anowl s Licenx Law forms
O O following reason.(Section 7(5 1.5,Business and Profecuu s Code:Any city Or county
y$ff which rop.l.a Peril to cnnsuum,alk',improve,demalah,m rtPat,any structure ^ 4..-
FIa, pursuant prior m is issuance also requires she applicant for such peril w file a signed statement
P�< that be is licensed puant to the provisionsof ma
e conracrs fucose Law(Chapter 9 Sq.Ft. Floor Area .(Q(/1 ////� 'UUJValuatlon -- - -
aft-$ (commencing with Section 71)11(Y)of Division 3 of the Business and Professions Code)or -
.- that he is eampt thartfrom and the bull for the.Ilcgcd exemption.Any violation of /
Section 7031.5 by any applicant for a Permit subjects the applicant k a civil penalty of --/�
e10 0 Occupancy Type - -
nmtmortOwn fin hundred dalWs(5500).
Dl,ssawneraf Ne property,mmy employees wis wagesutkir sok ampenssuon, " \
will do On work,and the A"ctam is not Intended oroffeud foreale(Sec.7061,Business
And Professions Cada:The Contrxmrs Lianx Law does no,apply a an owner or Required Inspections
property w ho William ireprove therton,end who dors such wart himsel f of through his
own employees,provided thrsuch impravemems art not intended oroffered for We.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that k did not build or improve rear purpose,of -
.ale.).
❑1,as awnc'of the progeny,am esCl.,IvAly contracting with licensed convectors in
convect the pmject(Sec.7006.Business and Professional Cade:)The Contractors LL
sue law dao not apply w an owner of property who builds of improves tartan,and _
who contracts(or such projects with a eonaacmr(s)licensed pursuant tithe Cantors - -
License Law.
❑I am exempt under See. ,B&P C for this
Owner Date
WORKER'S COMPENSTnON DECLARATION "
1 hereby affirm under penalty of perjury re of the following decluadowe
I ham and will mainain a Certificate of consent self-imum fm WorkersCompen-
ssturi.u provided for by Section 3700 or Ne Latin,Code,for Ik penam me,of On -
work for which di a permit is issued.
❑1 have and will maintain Waters Compensation Iosurana,u required by Section - - - -C3
3100 for the performance efthe woh for which the Permit is issued. -
My Workers CTrmpma.d n Insurance Cartier and Policy number arts
Cartier: 7—
carrier: Policy No.:241115/
CERTIFICATE OF E)(EMPOON FROM WORKERS'
COMPENSATION INSURANCE
Qhissection aced not becompleted if the permit 0 foronc hundred dallars(SIM)
M less.)
I arufy that in the performance of the work for which this Permit u bused,I shall not
employ any person in any mannersn As to become subject to the Workeu'Compensalion
Laws of Ca)ifamia.Date
Applicant
NOTICE TO APPLICANT:If.afar making Nis Ccr ificam of Exemption,you should
become subject in the WOrkera Compensation provisions of the Labor Code,you must
.,O forthwith comply with such provisions or this Permit shall be deemed revokc.
Z y CONSTRUCTION LENDING AGENCY
F-' l hereby affirm Nat there it.constmctinn lending agency lot the Performance of
O'. the work fur which Nis permit is issued(Sts.3W7.CO.C.)
lender's Name
= z Lenders Address
J Q 1 certify that I have read thio City
ad Court and sats Net the Shorn ws misting is
i -
0 U building
1 agree to comply with VI city and county matim of and sok laws relating to
W abovengcotionedonand rotebyauthodrzrtprtsenatiralof Niscity menter upon dm
} akve mentioned to ertysave(in emnify An imep ha
t„s D.O (We)egrte to ave,indemnify and keep harmless the City or Cupcnin0!
against
h Imbilitics,judgmcnts,Cosa and expense which may in My my accrucag.matsaid City
of OA lami
V z s limit.
APPL CANTeUNDERSTANDS AnND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREULATIONS.
return,ignu ofApplictDataT '�ke-roofs
07
an anor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant store or handle havardoua mean.)
as unlined by the Cupertino Municipal Code.Chapter 9.11.and the Heals and Safety
ode.Secur 35331(x)?
0y. Ind\'Nu
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
emit hazardous air contaminants As defined by On Bay Area Air Quality Management all new materials for inspection.
District?
❑secs u
1 have mail the 1vardouu5m.amnaH requirements under Chapter 6.95 offt Ca)ifor-
ALI RUM&SafClYCode.Section;25505,25333 anti 25534.1 undersand thatifthe building
docs wt Currently have a tenant that it u my nesporoibility a truly se,occupant Of the
��mqu¢mcnu which ntu et or k issuance of.Certificate or Qapmay. Signature of Applicant Date
w � 12 /2 a y
Owner of mtktiard a gent Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
/ C' 0 &-/z 6446FL eV 9?50/y G
OWNER'S NAME: - PHONE # 75g-
GENERAL CONTRACTOR:', FAX #
I am not using any subcontractors: ,, /, le-1 7 -15)
Signature Date
Please check applicable subcontractors and complete the following information:
66 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
c oo FURNACE /AC c) Z O /—?3
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 / Z Date:
6 ZDo � 12-
Building Address:
o '2 WC t
Owner's Name: Phone#:
Contractor: License#:
LJ -7760 3
Contact: Phone#:
Applicant/Contractor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq: -
ArchitecUEngineer: Valuation:
Type of Construction: Occupanc p:
Qt �
A i ble Fee ID Fee Description Fee Grou
BENERGY Ener -BUILIDNG .
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
B MREC Rec tl, Switch&Outlets ELECTRICAL
B EIS Seismic Fee Res BUILIDNG
SPERM E Elec Permit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUIL DNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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