05050065 (2) CITY OF CUPERTINO ' t �-'aal . •�'� ' ''" "�"
BUILDING DIVISION PERMIT CO�t��ACTOR INFURMATIOI ;
tial tie,: 5:,�'a',.. .,..� _s?^'�4+'ved'p•%- g;_. ,c.'�.;in t
BUILDING ADDRESS: PERMIT N0.
05050065
OnRn PRIVINS111A D1 111)
W NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY q9kOL NO.
AR CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� 0
BO a LICENSED CONTRACTOR'S DECLARATION
lY 1 Mreby affirm Nat I am licensed under previa me,of Chapter 9(ammcmieg Job Description
z1
with Section 7000)of DiWaker Jaffe Bminwand Professor.Cade.and my liccnm4
in rail ranee and erceeL REPLACE FURNACE & ADD A/ T�'J,�Njpl�#®
LIC
Section
Clans Contractor "�V�`IIgT��LLCC '
tit W< ARCHfIECI'S DECLARATION V
U 1 ummu and my plana shall he teed as public ra ah, /
ori� Licensed Pm2005
fcssional �i
OWNER-BUILDER DECLARATION L
F I herebyo.afflam(Scc Net 1 1. aempt from the Citions rs License Law for the
i O o following mason.(Scotian 7(171.5,Buimu and Pwfdaluu Cade:Any oily or county
$f<i which requires a permit to ceowucL alar.Impmw,demolish,lir repair any structure rif III Miss.
_�S^ pdarmits ivuence,Blau requima me applicantfonech permilw 011 aligned atammcnt
Nethcullanscdpurseentmtiaprovisionsn(1MConhrtswr'sLIecnselaw(Chapmr9 Sq,Ft. Floor Area
(commencing with Section 7000)of Division 3 of the Business and Reactions Cosmic,
that he is exempt therefrom and the basis for Ne alleged exemption.My violation of
Section 70]3 by arty applicant for a permit subjects the applicant In a civil penalty of 3 2WV jft*gr0 0 Occupancy Type
not more than five hundred Mariana($500).
❑1,as owner of the properly,ar my cmpla mos with wages u debaak compewtion.
will do the work ad thesuucture tsnotineen4d neoffmad for We(Sec.7044.Buumes Required Inspections
and Professions Code:The Conucm's Licensere law dahet apply w an owner of 9 P
property who builds lir Improves Mariann,and who dareauchwork himselforthrough his
awn employees,provided that such improvements are not amended moRcmd forsale.If.
however,the building or Improvement Is mid within one you of Completion,the Owner.
builder will haw the burden of proving that he did ret build or improve for purpose of
sats.).
❑1,as Owner of to property am acluaively contracting with licensed cantraseem m -
construct the project(See.7044,Business and Profession Code:)The Cm uwtoes U-
ants Law does not apply to an owner of property who builds at improves themon,and
who contracts for such projects with a comruter(O licensed puuuant in me Coruscate'
License Lou'.
❑I am exempt under See. .B&P C for this reason _
Civmr Dau
Ah WORKERS COMPENSATION DECLARATION
I hereby affew under penalty or perjury am of me following declarations:
1 have and will maintain a Certificate of Consent rotslbinsum far WarkersCompen-
ptian,as provided for by Section 37M of the labor Gude,fm Me Performance of Me
such for which this permit is issued.
❑1 have and will mainmin W Wke's Compensation Insurance,as required by Section
5700 of Ne Labor Cade,for Me performance of the work for which this permit u Issued.
My Warkera Cam ennuon l auras aerie" P_oliry number am:
Carder.
CERTIFICA •OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notbeeampaimi If tic permit Is foram hundred:1.11.(5100)
or leu.)
I Certify that in the performance of Me work for which this permit is issued,I shall not
employ any Forms in any manner m as to became subject to the Workms'COmpensaGOO
Laws of Ci
Applicant
NOTICE iO APPLICANT:If,after making this Cmifhcate of Exemption,you should
became subject to the Worker's Compensation provision,of the labor Code,you mut
.,O forthwithcom
with ply with such provisions or this permit shall be domed lowland.
'Z� CONSTRUCTION LENDING AGENCY
I--h 1 hereby affirm that tam is a anmuction lending agency for me perform race of
CG> me work far which this permit I.issued(Sec.2097.Cih,C.)
WM Lenders Name
D z Landers Address
U G 1 amity that 1 have mad this mplicadon turd sum mat the show information H
Iy" cones.I agree to comply with all city and county ordinances and sum laws relating to
0 building construction,and hembyaumadm apreanuuves ofthis city w a nus upon the
Lf7 show-mendoned property for IMPectian puryatsa
py (We)agree to save,indemnify and tap homeless the City or Cupertino against
`V)) Ilebilifies,judgmmnts,coast and expenses which may in my way acne against said City
in
APPLICANT A
OUN Uof Me NDERSTANDS thisof permit.
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EC TIONS.
12 Re-roofs
Signature,ffl-ApplicasoXantiggetcar Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at future building occupantuom or handle huardous nu u ill
as dented by the Cupertino Munieip 1 Cade,Chapter 9.13,and the Health and Safety
Code.Section 25522(07 All roofs shall be inspected prior to any roofing material being installed.
❑Yea u
Will the applicant or future building occupant use equipment or M aica which If a roof is installed without first obtaining an inspection,I agree to remove
It Incestuous air eontsminmts as sed by the Bay Ansa Air Quality Management all new materials for inspection.
DiurictT
❑Yes u
I have mad the huaNeus materials requirements tank,Chapter 6.95 or the Celifom
rats liealm@ Safety Card,Sccuom 25505,25522 and 25524.1 underauos than Irma building
does Out currently hove a meant,and It is my responsibility Or not is,dm occupant of the
reyucihmunMmmprior wiasuanccoflCeruncamafOcupancy Signature of Applicant Dale
1 I� EjS't2DY All roof coverings to be Class"B"or better
Owner or malmr and ftlifn Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
coo Fax(408)777-3333
�UPE(�TINO
Building Department
JOBADDRESS: (06804--WNSk - VE PERMIT#
c u 9 rra7i N z A goo dS6S Qa6f
OWNER'S NAME: L P S4, PHONE # g-
GENERAL CONTRACTOR FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation
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
- p
Owner/ ontractor Signature Date
CITY OF CUPERTINO 5�
ISE FURNACE/AC oS
CUPElkTINO PERMIT APPLICATION FORM
APN # 3 2
6 bZ
Building Address: /oo8D PErvWSUCA -AVE , CUPEPI1Nib , CA ) 9 ,'p/4
Owner's Name: Phone #:
T IRUt4P AT La LI H-NAN Q9, L5'S 1 03 06
Contractor: CTI U y P E`{ I�U L. D S License #:
9 ?> b 33
Contact: 408
, O8 /11 -1
-1 Zf 3 8 Cupertino Business License #:
Building Permit Info: d
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: k,46&— Mnac-Q , inS Q q Ac j CAUCV vkwv,
Residential [g-�' Commercial ❑
For Residential Insta ations:
Attic ❑ 1" floor 2nd floor ❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Project: �� Zs� Type of Construction: Occupancy group:
Strapped LJ On Platform Bonded LJ Sq.Ft. Floor Area: q OD
New Location ❑ Replacement 1
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energ 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
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING