04010007 (2) CITY OF CUPERTINO y�♦ ` 4 s��iy� `n*� � fir
BUILDING DIVISION PERMIT CONT)kACTOK-,4 \.a ORMATI41.A -
BUILDINGADDRESS: _ - A & H HEATING 111ITNQ,4010007
OW NER'S NAME: - PERMIT MUS DATE
ONE: SANITARY NO, CONTROL NO.
(408) 279-0722
CHITECTIENGINEER
08 279-
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
G7 E 1�
Cr o LICENSED CONTRACTOR'S DECLARATION- Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing P
nod with Seqt on 71)(10)Of Division 3 of the Busincysemd Professions Code.and my license is
imm�rn��ee'and.r t. REPLACE FURNACE FINALED
License, _ Ll.N�....(—S
c— Dare C.mactor R -r'7
ARCHITECTS DECLARA I N
D6uI und.hhnd my plans shall he used es Pyblie reenrds JAN 13 .2004
i C,_ Licensed Professional
OWNER-BUILDER DECLARATION
ji l I hereby affirm that 1 am exempt from the Contractors License Law for the BUILDING
COO fallowing Como.(Section 703 1.5,Business and Professions Code:Any city or county
O;� which requires a Permit b,construct,alma improve,demolish,or repair any structure
Prior n its issuance,also acquires the applicant for such Permit o n lc a Signed statement
< that he is licensed pursuant tadoe previsions ofthe Contractor's LicensmLaw(Chapter Y Sq. F[. Floor Area Valuation
tStO (commencing with Section 7")of Division 3 of the Business and Professions Code)or
3 Nat he is exempt therefrom and the baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant o a civil Penalty of 3 G1ffMN 9]el0 0 Occupancy Type
not mora Nan five hundred dollars(2500).
❑1,ax owner of the pmpeny,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered fora.].(Sec.7W,Business
and Pmfeschi s Code:
The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements ere not intended oroReacd for sale.If,
however,the building or improvement is said within one year of completion,Ne owner-
builder will haw the burden of proving Nat he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively convecting with licensed contractors to
construct the project(Sec.7W,Business and Professions Code:)The Contractor's Li-
cense law does not apply to an owner of property who builds or improves Neuron,and
who cmamets(or such projects with a contractor(s)licensed pursuant to the Convector's
Lkenx law.
C]I sm exempt under Sec. ,B&P C far this reason
Owncr Date
WORKER'S COMPENSATION DECLARATION
I hereby affnm under penalty of perjury oro of the following declarations:
I have and will maintain a Certificate of Consent toself--fi a me for Workces Compmn-
mtion,ssprovided for by Section 3700 of the labor CMC,for the Performance of the
work far which his permit is issued.
❑I him and will maintain Worker's Compensation Insurance,as requited by Section - -
]7W of the labor Code,for Ne performance of he work for which this Permit is issued.
My Worker's Compensation Insurance carticr ands PP hY nr�the art:
er:
Mee(��S P6yfy No.1V[�
C RTIFICATEOFXEMP79 NFROM WORKERS'
COMPENSATION'iNSURANCE
(Thu action need not becompleted if the pemtit is for onchundred dollars(SUgh -
ortem.)
I certify that in the Pcrfamunce of Ne work for which this permit is untied,I shall not
employ any person in any manner an as to become subject to the Woders''Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenincare of Exemption,you should
become subject to the Worker's Com ormation provisions of the labor Codc,you moa '
O forthwith comply with such provisions or this Permit shall M deemed revoked.
'�
tiCONSTRUCTION LENDING AGENCY
[r Ihereby affirm that them is a construction lending agency far the Performance of
ry' ate+ dm work fur which this permit is issued(Sec.3097.Civ,C.)
f>ay Q
header',Name
Z Lender's Address
V Q 1 cenify her 1 have read this application and Shur that the above information is
w correct.I agree la Comply with all city and county oNinmcce and ahk lawa!silting to
�O building construction.and hereby authome mpresenutives of this city to enter upon he
Uabove-mentioned Property for inspection Purposes.
ZLi (We)agree to save,indemnify and keep harmless the City of Cupertino against
gid Iiabili0es,judgments.costs and expenses which may in any way accrue againstmid City
fJ Z in consequence of the granting of this Permit.
APP (CANT UNDERSTAND AND WILL COMPLY WI NON-POINT Issued by: Date
SO C REGULATIONS.
gnaar arA' ntrcammeto A f DataD Re-roofs
HAZARDOUS MATERIAld DISCLOSUREType Of ROOF
Will theapplicant or future building occupantstorm or hendlc Into it us memriei
as defined by the Cupertino Municipal Cod.,Chapter 9.12.end the Health and Safety
ode.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the ap,pncaut or future building=upon(use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants is;Jenned by the Bay Area Air Quality Management all new materials for inspec[ion.-
hurler? �
❑Yes 13/
I have reef the amorphous materials requirements under Chapter 6.95 of the Califon
nice Hc"' Safety Cole.Secdmu 25505,25533 and 25534.I und.rsmnd thatRNe'boiling
dura not c seemly haw a mnan4 Nat it is my reaponsilrifl m notify dre a:cap.(of the -
reyvircr9 whichmum a oorR,'mumcccfeCtlli 10, Signature fifApplicant Date
Owner urDDDa Wn.d agent� •/' Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO a 6
7
FURNACE /AC
CUPEIZTiNO PERMIT APPLICATION FORM
APN # Co2 6 �q Date:
Building Address �� p
6O IILt'kl CT _
Owner's Name: �v pw PA � Phone #ks x.5,.5 So �
OO(( - _
Contractor: License It:
fu N�= T� � � 3oy�7a. _
Contact: Phone #:
D P.s .2 7q- to7�a
Applicant/Contractor: --
Building Permit lnfo: ----
Bld, Elect PlumbCl
ech
7
Job Descri tion: —
esidential: Commercial
q.Ft. Floor Area: $/SgtFt.:
Architect/Engineer: Vztluation: �,6_
0Type of Construction: Occupancy )up:
Qty. .
A) 'ca 1 Fee ID Fee Descri tion Fee Group
BENERGY Ener BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
RJBREM
-RE
CEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit Issuance L RICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Phimbin Permit lssue _ PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIVNG
BUSLIC Business License — �BULLONG
- ?,a 3 �