03100138 (2) CITY OF CUPER'f[NO -^'�*v »�:*'m'xf•�> �
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION'S
BU ILDING ADDRESS: ALTON AIR CONDITIONING & 'P�MITND.03100138
OWNER'S NAME: 45300 INDUSTRIAL DR 44 MRMITLSSUEDATE
NE: SANITARY NO. CONTROL NO,
(510) 490-5655.
ARCIIITECryENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
i00 LICENSEDCONFRACMR'SDECLARATION
-
;' I hereby affirm that I am hronsed under previsions of Chapter 9(commencing Job Description
with Section]MO)lel Divieion3afthe Busigqyy��and Professions Code,a dmy license is
lora. a e/$Dale /' REPLACE FURNACE & ADD A/C
r$Z Llcen c`AZ La. Q
I1- Dat Cunwelor
rq ARCHITECTS r 1
a aunt my plain shell E- used a Mie ret s /
u OWp 5 Licensed Professional
.] OWNER-BUILDER DECLARATION v
1 E I hereby alirm tial 14M eacmpt from Ne Contractors License Law for the
=G0 following reason.(Section]831.5,Business and Profemions Calc:Any city or county
j$ which requires a Permit to canmruct,alter.improve,demolish.or repair any structure
.Zi prior In its issuance,also requires the applicant for such Permit o Bic a slipped statement
that he is licensed lonuanuo the provisions or the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 $ (commencing with Searle.7").1 Division 3 of the B none.and Professions Code)or
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
31641042 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(5500).
❑I,as owner of the propeny,an my employees with wages u their sale compensation,
will do Ne work,and the structure is not intended or offered for sale(Sec.7044,Business
and Profeaions Code:This Conuacmrs License Law does nut apply to an owner of Required Inspections
property who builds or imposer Hereon,and who doessuch work himselrorilmugh his
Own cmployeei.provided that such improvements are not intended oroffered for tile.if.
hmweve9 Ne building or impowerent is sold within orc year arcompletion.Ne owner.
Wilder will have the burden of proving that he did not build or improve fa purpose of
uk.).
❑1,a owner of the limpenY,sin exclusively contracting with licensed contncton to
convect the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractor($)licensed pursuant to Ne Comrectori
License Law.
❑1 am exempt under Sec. .B At P C for this reason
Owner Data -
WORKER'S COMPENSATION DECLARATION
I hereby aRum under penalty of perjury one of the following declarations: -
I haw and will maintain a Certifiable of Consent to salt-insum far Workcr's Compen-
sation,as provided for by Section 37M of the labor Code.for Ne performance of Ne
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3]M of the Labor Code,for the Performance of the wed for which lM1ia PermilulaueJ.
My Workers m cation immacca 'crand Policy numkram: /�a�
Ca a Policy No.: 6
CERTIFICATEOFEXEMhION WORKERS'
COMPENSATION INSURANCE -
(Thu section need not kcomplcuol if the Permit is rorone hundred dollar(SIM)
or Icer)
I acidify that in the performance of the work for which this Permit is issued.I shall not
employ any Noun in any manner are u to kwme subject to the WorkeK Compensation
Laws of Cslifarnia.Data
Applicant
NOTICE TO APPLICANT:if,after making this Ceniricale of Exemption,you should
became subject to the Worker's Compensation previsions or the Labor Code,YOU must
�O forthwith comply with such provisions nr this Permit shot]k deemed revoked.
r` CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat More is a cmtstructinn lending agency for Me rerform ra a of
Yd > the work(ser which this permit is issued(Sec,3M7,Civ.C.)
Y0 Lenders Name
Z lenders Add.
;)Q 1 terry that I have read this application and state that the show information is
y F correct.l agron to comply with all city and county ordinances and sale laws elating ld
�U building convection,and hereby authorize representatives of this city to enter upon the
4 abmomentinned P OKUY(or inspection purposes.
ti (We)agree to saw,indemnify and keep harmler,the City of Cupertino against
cn liabilities,judgments,costs and cxpensiss which may to any way scout against aid City
;J,Z in cansequenec or the grouting of this Perm it / O
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CER T
Re-roofs
Sig Ap c H2Auacor Data
HAZARDOUS MATERIALS DI OSURE Type of Roof
ill the applicant or future building occupant slope or handle hasardous material
as dented by the Cupertino Municipal Code,Chapter 9,12,and Ne Health and Safety
Craft.Seetian zss3z(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yee
Will the Applicant or(alae buBAngoc, poor use equipment or devices which I If a roof is,installed without first obtaining an inspection,I agree to remove
11 haurdnus sir conaminams a dcE y the Bay area Air Quality Management all new materials for inspection.
istricR
❑Yus _ u
1 have read the laysrddms materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code.Seedau 25505.25533 and 25534.I undeutnndtWl if the Wilding
Jos ata cunen0y hoe a tenant had it u my responsihility to oodfy Me accupat of the -
u m nth u ma prior 4,Issuance or,CcniBc at euaney. Signature of Applicant Date
Ow er ahoorixed agent Doc All roof coverings to be Class nBn or better
CITY OF CUPERTINO
FURNACE /AC 0 3 ( a ( 3
CUPER-TING PERMIT APPLICATION FORM
APN # O Date: ! 6
Building Address:
o a� 3 'N own dove,
Owner's Name: Phone#:
Po a� ,kclh X40? -as-1- aya
Contractor:( License#:` a
Contact: Phone#:
S to - L490—Slo SS
Applicant/ o tr ctor. /� �A,
/1 1a?,_ - Jul'y--
Building Permit Info:
Bldg Elect Plumb Lmech
Job DescriptioK. cl`1ZA;VN kVCZZO\!- C-
Residential: ereitrl- t —
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuatio
• Type of Construction: Occupancy Group:
Qty. if
A ble Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
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 BUH IDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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