05110105 (2) CITY OF CUPERTINOy'�+t'h
r
BUILDING DIVISION PERMIT ECI,U, NItACf�ORINE'C},,�x
But
ADDRESS: STANFORD PLUMBING HEATING &AI TD'05110105
11004 NORTHSEAL SO
OWNER'S NAME: PERMIT ISSUE DATE
PATTY WILT 1965 KILE
SNE: - SANITARY NO. CONTROL NO.
(408) 286-8931
ARCHTTECTIENGINEER: BUILDING PERMIT INFO
'BLDG ELECT PLUMB MECH
0 � 0
Sop LICENSED CONTRACTOR'S DECLARATION lob Description
1 Wmby affirm WI 1 3 fft Bu under pmvisioos of Chapter 9(commencing
with 7070 DMdon3oflhe Business grid Profasnom mylicewcu
14Lknma REPALCE FURNACE & ADD A/C
l ? Lkenw Lk.N
3 Daw ARCHITECTSOECLA N J
1 I understand my plane shall he used as public mcorcis ygqmy0 A1V
s� Licensed Professional OWNER-BUILDER DECLARATION /};'J /qq/ ZOOuv
a C 1 barony.1111M(Sec that 1 1. exempt from Use Conon,Co License city
o for du
p o following resmn.(Salon 71131.3,Business anti Improve.
adem h,or Any city or aunty
S$�
which rtqulres a permit m eonmua,atim,mprom.demnlW,or repair ane atmcture se4 0 0(]
z 1„' prior In its issuance. ]an requires the applicant For such permit he File asitned nawmem
< that he is licensed purmm,to Me Provisions of to Conuwtm's License Uw(Chapm9 Sq.F[.Floor Area Va ualjo'.
5E�9 (commencing with Section 7000)of Division 3 of the Business and Pmfesdow Code)or
— twIM
that he is empt mhom and the bash for the alwgcd on MY violidoexceptin of
Section 7031.5 by any applkam for a permit subjects the apPOan,w.civil penalty of f Occupancy Type
rot more Wo five hundred do1Wa(S300).
❑1,as oam of the property,or my wploym with"San as two sole ampenndon,
win do Mewort.and ft a mit rot I.=a offend for tab(Sao.7011.Budrcss Required Inspections
and Professions Cade mumlm The Ctors LkecLaw dean rot apply w an owner of q p
Property who builds mIeProw thermmand whodoes muchworkhimwlforIh math his
own employee,provided dm such impwwmenu ars,rot intended oroRerrd forale H. '
nowever.the building or Improvement Is mid walk arc year of 0 mPktion,dee ewner-
builder NB have dm When of pmviaS that M did not build m hop.fa puryom of
slat
❑1.u owner of W property.am exclusively contracting with w-^••^cormuctors w
construct the project(Sec.70,14.Bwincta snd Professions Code)The Contramoss U.
came Law does an,apply to an caner of propenywho Wilds or Improves Merton,and
who concis for such projects with a conlractor(a)licensed pormanl an Me Gnouctoes
License Law.
❑I oro camp,under See .B 3 P C fm this mss on
Weser Data
WORKER'S COMPENSATION DECLARATION
I hereby arm under penalty of perjury am of the following decimatom:
1 ham and will mdnWn aCuNEamaf Omanum w seif-iaum fm Werless"Cempem
ewes,as pmvidcd for by Section 3700 of the Labor Code.for the pmformame of the
wort for which this permit is issued.
❑1 have and will maintain Wer Ws Gmpentsdon Interrupts.as required by Semen
3810 of Ow Labor Code.for the performance of the wit fm which this permit u immuL
My Wo ompe soden IwrarNe and Policy n ism K:
Grrier.�Policy Ne:
CEIt'TIF1' TEOF COMPENSATION
NFILkNCE KERS
COMPENSATION INSURANCE
(This section need mu be cmnplemd alba permit Is(mane hatredm aa($100)
or lex)
1 aNfy that In the performance of the wart for which this permit is issued.I shat(an,
employ any person in my manner an a m become mbjen to tee Workme Cmnpmuaden
Laws of California.Dau
Applkml
NOTICE TO APPLICANT.If.after making this CcrdRaw of Exemption,you should
become subject as tee Weakens Compensation pmvisiew of Ne labor Cade.you mum
.J O fonhwhJu comply with men prevision"or this permit shall he dcemed revoked.
z ti CONSTRUCTION LENDING AGENCY
E4 I hereby alarm that them is a construction lending agency fm the performance of
a the work for which this permit is used(Sec.3097.Civ,C.)
W�Q LendeM1 Name
Z) Z lattice,Address
U0 I cmU4 that 1 have read this application and sum ten the abave information is
U.;'^ corem i agree at comply with all city and county mdimnees and sum sews relating to
O SU•' Wilding construction.and hereby authorize representatives of this city mcnm upon Me
W above.mentioned properly for inspection purposes.
y (We)agree m am,indemnify and kap harmless the City of Cupertino agalmt
o-w rA liabilitn.Jud meats onsandeapcows whknmaymanywyamueagtloslsu City
F4ince f grandestofMLh=PZIL
w. APPLI ERSTANDS AND WILL COMPLY WITH A NON POINT Issued by: Date
SOU TIONS. K
U� Re-roofs
Signs, ofA1.9cm Dam
OUS MATERIALS DISCTASUIIE Type of Roof
Will0a.ppliantorfm IdingempantmommhaMle haallow maurial
A.L.defied by the Cupemna F re Cade.Chapter 9.u.and du Health and Safety
ode.Seeum 2533:(.)7 All roofs shall be inspected prior to any roofing material being installed.
II'
wIIthe applkan, ramm banding=upset we equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
.mit h.rardnw air cmumi "n Omd by the Bay Ams Air Quality Management all new materials for inspection.
Disulct7
❑Yes No
1 m the lunrdhuu mamdab rtquirtmcnu undcrCTupesrd.93oftheCaifor-
mali I I Qndn 25303, 333and25331.1ummnunti Irthc Wilding
dos c 11 naw nal,Nu it m,pmuihllity w notil' aces thin.oftee
regul me h h be mel rior iv ofaCeME" of Signature of Applicant Date
owe rmthe mdacem Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
it � Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT#
I 06 q ftiY eGC 01' /'d/ D .1-
OWNER'S NAME: Ij/ I t PHONE f
GENERAL CONTRACTO •,4 G ( o FAX#
I am not using any subcontractors: Z�lzI I (p 6,
igna a Date
Please check applicable subcontractors and complete the following information:
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
caner/Contracto ignature Date
CITY OF CUPERTINO
FURNACE /ACS-
CUPERTINO PERMIT APPLICATION FORM
APN# / Date:
G 6( l
Building Address:
� a G �ea-
Owner's Name P nne#:
C G
Li ens e 4(-.
Contact: [ pe�.
Applicant/Contrac
Building Permit Info:
Bldg Elect Plumb ✓ Mech
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuati /1
• Type of Construction: Occupancy Group:
Qty. if
ApplicaFee 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 & Ouilets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BULLIDNG
BUSLIC Business License BUILIDNG