05030173 (2) CITY OF CUPERTINO xx
BUILDING DIVISIONCONTRACTOR INI;'O A." IOi �,l
PERMIT re �n tr, .;.� k
BUILDING ADDRESS: J C HEATING & AIR CONDITI ) aaO 05030173
247S PALM AV
OWNER'S NAME: FERMIT L411EDATE
JIM BODWIN 1900 COMMPRCTAT, WAY -0-2 1.1 2 In In c;
.ONE: SANITARY NO. CONTROL NO.
(831) 425-6538
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGp [� eLecr PLO O
yoz LICENSEDCONTRACIORSDECLARATION Job Description
1 Wmby afOw Nat 1 am IiauNcd umkr provWam of Chapter 9(commencing
with Secam
on 7tKII)of DlvWan 3 ofthe Bualrcu old ProtcuioNCode old my license h
4❑ nmuron'eerce4. �g G1ps�q () REPLACE FURNACE & ADD A/C
z Littnx Clsss
?g7 Dam Co.IrsnOr i
ARCHITECTS DECLARATION
I undcraund my plans shall be used as public maor0
7 U
yc Licensed Professional
u OWNER-BUILDER DECLARATION
I hereby affirm Net 1 am morpt from the Contractor's License Law for the
C o fallowing mann.(Section 7130,Business and ProfesdaN Cade:My city or Monty
$ which mquires a Permit to construct.alter,improve,demolish,nr repair my soneco m
Fly prior to im issuance.abu mefires;the applicant for such permit w file a signed statement
< NalbubliccNed pursuant to the provisions of the Commutes Uccuse Law(Charter 9 Sq.Ft.Floor Area Valuation
(ctunmorming with Section 70DO)of Division 3 of Ne Business and Professions Coca)or
9 dui he iseumpt therefrom and Uu bub fm We alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty ofg.[�&81hhlSbr 0 0 Occupancy Type
not more than five launched dollars(5500). /ny
O Lu owrmofrbipropoy.ar myemployces with w{cau Near rete eompewtlon, /'n n
will do the woh.and Ne mocwm is rut immanded aralfered funale(Sec.7044,Bodtm "rr v/
and Protessimu Code:The Conuacub License Law don not apply wan owner of Required Inspecuonsy. A
propenywha builds orimprovu thereon.and whodoessuch work himself orlhrough his
own employ=.provided that such imprommmts are not intended a offered for at-it.
however,the building or improvement is sold within ane year of mmpktion.the owner. �✓'AQ�/ W
builder will hem Ne burden of proving Nn he did not Wild or Improve for purpose of /� 4
Const. /(,.y)Q ��� 90p�
❑1,u owner of de property,am exclusively contracting wit liaeued conuacmrs to /C/-1'JCf/fzJ%/!// C
Caoswct Me,dproject(Sec.70th,Barmorof and rtywhooNCade:)The mthem .and cense law don not apply to ut owner of property who Wilde or Improve them".and
whocontractsLace for such projens with aeonumur(s)Ilnnxd punuamwNe ContnnoM1
License
❑1 em exempt under lee. .B h P C far this reason
Owner Dau
WORKERS COMPENSATION DECLARATION ' ' ' . -
I hereby 4111m under penalty of perjury arc of Ne following decholumse
I ham and will maintain•CeniBcslc orConsent to selFinsum for Workers Comperl-
.It..,as provided I.by Secd..37M of the labor Code.for this peRormmen of Me
woh for which this permit is iuucd.
❑1 have and will maintain Worker's Compensalion In mar ce,as mqunmd by Section
37W of Ne labor Code,for the periormance of Ne work fa which this permit is issued.
My Wohee's Comlerwtion INurann airier and Policy gnvumber art:
tinier. F/.f y`Yaa lkr') In.5 Policy No.: (4 I� OI
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section Med not be cmnpined if the permit b foram hundred dollen(SIM)
or ICSL)
1 ceniry Not in Ne performance of Ne work for which this permit is Issued,l shall nil
employ any permn in my mmrrerm as u became subject to dieWorkers'Compenution
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenincate of Exemption,you should
become subject u Ne WNWs Ci mpmwdon provbiona of the labor Code,you muff
.,0M
fowith comply with such provialN
nN or b m
Permit shall be accrued mmkeE.
z= CONSTRUCTION LENDING AGENCY
lw t hereby afBam Nal Nen it.com muslin lending agency fmthe perfamancc of
fYithe work fur which this permit b Issued(Sec.3097,Civ.C.)
Lett Q Lenders Name .
.7 Z Lenders Address
U O 1 certify that 1 Marc read this application W tam that am abum Information Is
D.F Cowes 1 agree to comply wit all city and county orthoses and sum laws relating In
DU building construction,and hereby autoodre mmesenumes of this city in enter upon Ne
Gl7 aburo-mcnlone l pmpcny for inspection purposes.
gy (We)agree to Com,indemnify and keep hawless Ne City of Cupertino agalNI
Lo) liabilities,judgmcnu.costs and experun which may In my way acne against said City
(.1 7 In C.Nareem.of Nc granting of this permit
Fi APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC LATIONS
14-0 Re-roofs
Si{n sof Applica uCantraclor ' Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or ruuue building occupantslom or handle hamdous material
Cw d lned by du Cupertino Municipal Code,Chapter 9.13,and Me Health and Safety
cads,SOedon 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea ff<
Will the applicant or future building Occupant Cox equipment in devices which If a roof is installed without first obtaining an inspection,I agree to remove
7Eqe?zz1
t hamoous air conuminmu u defined by the Bay Area Air Quality Management all new materials for inspection.
rict? —/
❑Yes you
1 hears mad the brando s materials mquimomm underChapmr 6.95 of the Califor.
alth@ Safely Cade,Sections 25505.25533 and 35534.1 understand that Ne building
Out c.a0y hom•¢assn.that it'udrIy responsibility u notify the oceupmt of the
amba 'pdorwiilu.of.0=11.8mofOccupancy. Signature of Applicant Date
3l 1`-��
Owner or ouNonveOagent Dau All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
a[ F Fax(408)777-3333
IOUPEI�TINO
Building Decutment
JOB ADDRESS: PERMIT# O r� v
a,L , v-e-
OWNER'S NAME: Z-t w 6 ,0 IPHONE # qOf 8W2 uq L(
G£NER*L CONTRACTOR J'.e. (+,z�4} �, A �¢� t FAX# `40e 1'1- 0-7 tLi
I am not using any subcontractors: 3 — ( 6' 0
Signature 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
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
�uPEr�TiN0 PERMIT APPLICATION FORM
APN# Date:
*3S'? 0 3 696q 3 ^ iC- os-
Building Address:
22"`x- c h. A v
Owner's Name- Phone #:
�Odk/Ih tio,'- ?1-�- - L4
Contractor: ll Phone: 3 I License#:
G.S30? eyOS- 2QU
Contact: Phone: Cupertino Busi es s License #:
�a�� 93 1 37&-L'3S 2
Building Permit Info: \
BldgE) Elec� Plumy ❑ Mech
Job Description:
1 ce FvVKtce_ Ada e.
Reside tial ® Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ® 2"d floor�
dhere to min set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
14 I'3^7 _.s0
Strapped ❑ On Platform D Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
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 BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMI`FEE Elec Permit Issuance ELECTRICAL
NTERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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