05030015 (2) ' CITY OF CUPERTINO ww�s�kTrg� �y,:2iFf '��r3��f+� '7`�7e�",•k`'' 4�" r
BUILDING DIVISION PERMIT aCONTYtA.CTUR IN'k'U,ItMAT�'QV r :,
BUILDING ADDRESS: GAFFIGAN CO. PERMITNO,5030015
OWNER'S NAME: PERMIT Umu DATE
ZONE: SANITARY NO. CONTROL NO.
(650) 574-S 40
ARCHIT ICTIENCINEER: BUILDING PERMIT INFO
BL DO ELECT t� Pot t�
rsUMB MBCH
p Zp LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(emmmandng Job Description
With Section 7M)of Divalon 3 of the Business,and Pro amino Coca.ad my license is
n nfmlfarsnandeffm �� y REPLACE FURNACE & A/C
5 J License CI Lk.R
Z Dau Conuacmr
9 ARCHITECTS DECLARATION
I understood my plans Nall W used u public mcmds '
o u
G
Licensed Pmfcssionel
OW NE.BUILDER DECLARATION
E a i I hereby mea .(Sinn Not 11. exempt from Its,Cosines Co Licence Law for the
Ea O O which re reason.permit
t 7fD1.5,Business and Improve.
de ons Code:Any city or county
Lure
u�$ which its im Inca pewit re sirescomentruct.slut Improve,demolish,m re sig any struccomment �-
L.Zi prior biuiensedp chore to the thovisios of for smhpermit mRlu sgneduaumenl
EEC
Sq.Ft.Floor Area Valuation
y zEG (cwnmeneing with Section 7000)of Divlaionlof Nc Businevand Professions Cndc)or
3$
that he is exempt tMmfrom and the basis Re tk alleged exemption.My violation of
Section 7031.5 by my applicant fm a permh subjects the applicant to a civil Mostly of 3 56MJ9tiTOM 0 Occupancy
not mom than five hundred dolt.(S500). p y Type
❑Lasowmsof Nepropeny,mmyemployces with wagesuthormlacompendon,
will do the wotlk and the structure ts vel msnded oraffemd formic(sec.7044.Busimaw
and Professlan Cade:The Commemta Lkeme law dam oat apply to an owner of Required�nspections
progeny who builds Or improves themon,and whodoessuch weak himu!(mthmugh his �1 iet
own employw,pmWded Nanmhimprovemenu art vot intsMed maEerMfmnklL (� 1, I
however,Ne building a Improvement Is Bald within oro yeti ar Improve
for
the owrcr-
bWlder will have tie burden of proving that ke did not Wild ea improve Ice puryeac of ^
tile.). dr4 ` let.
[:)Las..,of tie property.am exclusively cormearg wish lk<med cenuum t N �f
construct the pmjen(Sec.7004,Business and Professions Cotler)The Cont a war's Lt.
cense law door not pply at an owner of property who builds or improms thereon,ad
who contracts for such projects with a cwmuror(s)licensed pumwnt to the Consacur's
1 am law.
0
Lem exempt under See. .B&PC fm Nb moon
Owner Dow
WORKER'S COMPENSATION DECLARATION"
I hereby a m under penalty of perjury oro of Nc following dedantions:
Ibam and will mainuina Cedric{mofConuntioulf-Insumfor Workce Campen-
setion,as provided for by Section 3700 of the labor Code,few the performance of we
work for which this permit is issued.
❑1 ham and will maintain Worker's Compensation Insurance,as nequimd by Section
3700 of she Iabnr Code,fur the performance of she work fa which this permit is issued.
My Worker's Compensation Insurance aaior and Policy"A
rOn -Z.bD
Carr4r. 9.4A"v$-a Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secem need not becompleed if the forest,]arm=hundred deltas;({101)
or toss.)
I certify that in the perfmrtnanee at Ne work for which this Permit is issued.l shall not
employ any person In any manmrsn at to Weeme subject ro tM Weaken'Campemdm
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Certificate or Exemption,you Nwld
become subject m the Worker's Compensation provisions of the Lahnr Code,you most
0 O faMwith comply with such provisions or this permit shell be doomed revoked.
z CONSTRUCTION LENDING AGENCY
[.v I hereby aRnm Net Nem its connxtion lending agency forme porformmce of
> the work fur which this yennil is issued(Sec.3097,Civ.C.)
aE Lender's Name
z Lender's Address
UR I cedfy that 1 Mm mad this application ad sou Nn we above information 6
Ito wrmcl.1 agora to comply with all city and county mommas and IWC laws mladng to
0 building construction,and hereby authorize representatives of this city to enter upon the
W stave-oun timmd property for inspection purposes.
(We)agree to ave,indemnify ad keep harmless the City of Cupertino against
ti labilities judgments,toss and expenses which may in any way accrm against aid City
in conugmnu of the gmndng of this permh.
�i APPLICAT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE NS. / /
°t Re-roofs
Signature of Applicam/Conuamr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applkam or future Wilding occupant nom or hands hazardous material
u de0oed by she Cupertino Municipal Code.Chapter 9.13,and Ne Health and Safety
elide. C3 es zss3:(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea
WIII the applicant or forum building occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Il hmultdnus air corumimanty u m
de0d by the Bay Area Air Quality Management all new materials for inspection.
vlet7
❑Yea agMb--
1 have and the hazardous maurlalsmquhements under Chapter6.95 of Oat Califor.
nia Health&SefctyCode,&do.215113,35533 and25534.I taxa and Lha fshe building
docs not c...IlLitarAwnelm,that it is my reasonability to notify the=opal of the
mquiromcntsw ch melpdorah3usoccof.CwiGceuofQcupancy. / ignature of Applicant Date
3 i q
Owncrur auNorinede cot" Dam All roof coverings to be Class "B"or better
aclF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#�S—� 3 00
os f-.S 0 pfd. .
OWNER'S NAME: •LL ^n c..n+;LL A/J PHONE # (Sv— s-) Y—s7 o
GENERAL CONTRACTOR: C-4-Fi 6-*.a [•0 . FAX # 6 y� 79— zyoo
I am not using any subcontractors:
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
Wi . FURNACE/AC D S 3
CUPERTINO PERMIT APPLICATION FORM
APN# Dt
3r6 ae: 3//Joh,
Building Address:
o� (LI-S i/Jio A 2
Owner's Name: Phone#:
3 —S"4
Contractor: License#:
Contact: Cupertino Business License #:
Z3 / o3
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech l�
Job Description: � _ " "
(pL&F ern.£ a' /4L T Loci inti
Residential dS, Commercial ❑
For Residential Installations:
Attic 6z-1 St floor LJ 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
vh 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:
672a -
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN 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