05020180 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONURACTORANFORMATION
BUILDING ADDRESS: _ CONDITIONED AIR P�IMITN'05020180
OWNER'S NAME: PERMIT ISSUE DATE
SRINIVASA
ZONE: SANITARY NO. CONTROL NO.
(408) 291-2220
ARCHITECTIENGTNEER: BUILDING PERMIT INFO
BLDjL— E�� PLUM= MECH�
uo0 LICENSED CONTRACTOR'S DECLARATION ® I=
UF 1 Wreby anion that I am licensed under provisions of Chapter 9(commencing Job Description
z1W with Soclion7")of Division Sof the Buaims,md Profession,Code,and my license is
K!
j�on mful o mfilnmaand er t. ` L I ; °J FURNACE IN ATTIC & ADD A/C
s Lic.g
Dam Conlsacrr Iwo A A
ARCHITECTS DECLARATION
3: lundcrven am Nai used wpu6lie records \�%
3 u Licensed PnZ�lsionel /.7 ~ .VY
OWNER-BUILDER DECLARATION X
'i1 f I hmeby afrm that 1 am eacnpt form the Courratwes Liunse Law for the \
HO O following mason.(Section 7031.5.Business and PmRviom Code:Any city or county O \
which requires a permit to enm m.alter,improve,demolish,or repair any structure
< prior to its issuance.also requires the applicant for such permit to file a signed aulemcul
ZO that he is licensed pursuant tolhcprovisions offtConnector's Lanshw(Chapter 9 Sq.Ft. Floor Area Valuation
m�$ (commencing With Section 70)0)of Division 3 of NO Business and Professions Cukor
— trust ha is exempt therefrom and Ne bssu for the alleged exemption Any violation of rnwn xs
Section 7031.5 by any applicator far a permit subjects she applicant to a civil Penally of 6�NiffiEbci0 0
not nam than five hundred dollars($500). Occupancy Type
Q 1,u owns of Na preptny.a my employess with wgu u thea tele rompensatim,
will do the work.end the msec ure is Out intended or offered portals(Sec.7044,Business
and Profession Code:The Contractor's License law does sat apply to an owner of Required Inspections
property who builds or improv thereon,and who does such work himself or through his
own employees,provided Our such improvements are not intended moRered for sale.If.
however,the building or improvement is sold within on,year of completion.the owner,
builder will have the burden of proving Nal M did not build or improve for purpose of
.It I.
Q 1.as owner of Ne property,am exclusively contracting with licensed mnoxrors to
comtrvcl IM pmjeu(Sec.7044,Business and Professions Code:)The Commcnri Li-
unse law docs not apply to an owner of property who builds or improm theme.Md.
who contracts for such projects with a eormseror(s)licensed pursuant to the Contractors
License 1a W.
❑I am cnemis under Sec ,B k P C for this m•.on
Ownu� Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury on,of tho following decimations:
I have and will maintain•Cenifseate of Conant or self-insure for Workers Compere
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Wmkers CompensauM Instar .as required by Section
700 of Ne labor Code,far dm performance of Ne worts for which this Permit is issued.
My Workers Compensation Insurance canis and Policy number art:np
Grier. �rf 3iicTlr's\ �\OS(PolicyNo.: �'I II'ICtg_
I CERTIFICATE OFEXEMPION FROM WORKERS'
COMPENSATION INSURANCE
(This scrim need not Mcomplerd if the Permit is forone hundred dollars($100)
nr Its..)
I unify that in the perfnomarcc of the work for which this permit u issued.I shall not
employ any person in any manner an as re Wcomc subject o the Workeri Compensation
Laws of California.Date ,
Applicator
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Woheb Compuualion previsions of the lahm Code,you must
.,O foMwith comply with such Previsions or Nu Permit Nall W dumcd revoked. _
'Z..'h CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem is a construction lending agency for the performance of
C ted woh for which Nu Permit u issued(Sec.3047,Civ,C.)
W 4ndw's Name
z Lender ddrcas--
U Q 1 coni rI base reed Nis applicaum and sum Nat Urc about infometiun is
U.F cones 1 egme w c ly with all city and county ordinances and state laws relating to
0O Wildingmmsoumian,an rebyauthorim representatives of this city m norm upon dre
Mem or mond Property(m sGm purpoxs _ -\
H 0. (We)agree to save,indemm kup harmless the City of Cupcnino against
Z inconsequedgmcnts,gramind of rr.w ey in any way varve against said City ///Date
t.)vz in ronsegmnu of the granting of Nis permit
^ APPLICANT UNDERSTANDS AND WILL COMP L TH ALL NON-POINT Issued by:
SOURCE REGULATIONS. O
A-4440urcRe-roofs
App r[MM tr is 'Dar
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future building auupant More or handle hanNous mamrial
ss dcfimd by Ih Cupertino Municipal Code.ChaPlm 9.12,and Nc HcaW and Safety
ode.Section 25532(a)?
El Yea _.'�INm All roofs shall be inspected prior to any roofing material being installed.
Will the applicant at future building Occupant use equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
7o0.nd,&.,thmi.d
rit hazardous air contaminants u defred by IW Bay Arta Air Quality Management all new materials for inspection.
iWict?
❑Yes �Nu
I have mad the hvm
ardnussterials requirtments underChaprrti.95 of doe Cslifor
iastHcafthh SafcryCode,Sectors 25X15.25533 and 255X.1 understand thxtifthe Wilding
onal currently hath.'a tc,ML Nal it la my maPonslbiliry m notify die=UPNI Of Ne
I ntawhichmuRW Maim r oftc,scruarofOccupancy. Signature of Applicant Date
b46& ti �:r9/��,/n S
asdtit �..i new All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�
CITY OF Fax(408)777-3333 UPEkTINO
Building De artment
JOB ADDRESS: PERMIT # -
Or ,r. C50 90 l $O
OWNER'S NAME: va �t PHONE # C4oS) 04 -9�*.5
GENERAL CONTRACTOR: } FAX # C g gq 1 • 9-b*y
I am not using any subcontractors:
Dal-,4A- &6�—
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
a JL/0 S
Owner% ontractor Sign,iture Date
CITY OF CUPERTINO
0- or FURNACE/AC v S'
CUPEkTINO PERMIT APPLICATION FORM
APN
Building Address:
7 5 e bI o &rn ':DR.
Owner's Name: Phone #:
Sri lynsa DedO9• a qQ q7a
Contractor: Phon : License#:
ac, , qt - 445I Io ;k.—
C ntact: Phone: Cupertino Business License #:
U,,u aqI- aaa as a
Building Pe it Info:
Bld cpl— Elect Plumb El--' Mech Ur--�
Job Description:
l'u.+'r, . t a c_ add on
Residential„� Comfnercial ❑
For Residential Installations:
Attic —1 S` floor ❑ 2"a floor❑
Adhere to min set back re uiremeraD,
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning A roval Required ❑
Cost of Project: Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Re lacement ❑
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec ti, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
k MPERMITFEE Mech Permit. Issuance MECHANICAL k' PPERMITFEE Plumbin Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING