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03120105 (2) r' CITY OF CUPEWrINO BUILDING DIVISION PERMIT VCC0NTRACT0R,INF0RMA'CIO , OUILDINGADDRESS: - PERMIT NO.03120105 OWNER'S NAME: PERMIT ISSUEDATE NE: SANITARY N0. CONTROL N0. ARCHITECT/ENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MF.CH t� 0 t� :GC LICENSEDCONTRACTORS under previsions IWrcby affirm That licensed under provixioni of Chapter9(cnmmcncing - Job DCSCrIptlOn ¢� with Sectio )of Divi'an 3 of the Bus! and Profession,Code,and my license is p H in full fort effect. ^ z License a LI,.g _ FURNACE REPLACEMENT m Date camrw CONTRACTOR: JIM' S AIR CONDITIONING -ARCHTIELTS DECLARATION } �i undcraunJ my milWl W used a public rtenrda C. Licensed u F' Licensed Profcuiond ��0.s 3 E DECLARATION (f1't��... P I hcrchy affirm t I I�aTii pt( the Contractor's License Law far the "`z7 ypCl following reason.(Sccdan 7fOI.S,Buincss Md�fcsdutts Coq:Ai ylcity or caun S$ which teyuircs a permit to Construct.Biter,improv,demolish,dlj re r any a nu��"' _iy prior In its issuance,also requites the applicant for such permit to0lea gnat se m I- £r; that he isliccnacdpursuemlothe pmvisimsofWeComucwr'sLicenulaw(Chapte Sq.Ft. Floor Area Valuat�2500 ytt$ (commencin6 wilhStaion 1IX10)of Division J of the Businessland Professing.Code)or 3.. that he is exempt Ncmfrom and the buss for the alleged exemption.Any violation of Section 7071.5 by any applicant for a permit subjats as applicant to a civil penalty of APN Number Occupancy Type not mom man give hundred dollars(6500). P Y YP ❑1,nownerortlupmpiny,mmyemployeuwimwegesumeirwlecompenutlon, 34232030 . 00 will do me work and me structure ism,intended or offered for sato(Sec.7064.Biologies gond Professions Code:The Cortisones License Law does not apply tow owner or Required Inspections prapeny,who buildsor improve bemon.and who doessuch work himsolf or brought his own employces,provided than such impha emenu am not intended or offered forsake.If. however,the building or Improvement amid within ane yeti of completion,the owner. builder will have be burden of proving that he did not Wild or improve for purpose or ulcJ. ❑I,as owner of be property.am exclusively contracting win licensed convacton w, Construct the project(Sec.7044.Business and Prefesdons Code:)The Contracwrs U. vee Law does not apply to an owner of property who Wilds or improves Woman,and. . who contacts for such projects with a conuacwr(U licensed pursuant o dm Contractors 'cense Law. I am exompl Whim See ,B gs P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under pemlty of perjury one of be fallowing declarations: I lose and will maintain a Cenificau of Constant eto self-image far Workers Compcn- sation,u provided for by Section 37M of the Isbor Code,for the Performance of the ' work for which this Permit is issued ❑I haw and will maintain Worker'Compensation Insurance,as reignited by Section 3700 of We Labor Cade,for be pernm once of the work for which this permit is issued. My Workers Comminution luurance tinier and Policy number are: Carrier, Policy No.: _ CERTIFICATE OF 13)(EMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need notal completed l(thc permit is raranehundred dollar.($1(X)) In ova) I canify that in the performance of the work for which this permit is issued,I shall not employ any penan'n trot sou uhccomcmbjec5 to the Workerd Compensation laws of Califomi. OApplicenm TO APPL L after meting this Certificate of Exemption,you should ' e subject to I Yorker's Compensation provisions of the Labor Cade,you mail .J ,Z forthwith Comply at such provisions or this iti miuhall W deemed revoked. . z-O \CONSTRUCTION LENDINGAGENCY v I for w +Rvm ren theta its consSm.3 7.Cin (•-' Y pgcmy rte rine lerrurmettce ser ai M the work for which this permit b intrad(Sm,7097,Civ.C.) tg1 Q Lcedch Nun. �z Lcndeh Address ' IL Q 1 ttme bat 1 have mad his city and coup and suss that be aWv infotmating is IL F builds.I grtt to comply with all city sed mpims.Nims of and sou laws retailing to W gbove-gcotionod n..and hereby rinpoohonpurposesenuliws of this city to enter upon be W ahovcmejudgidps,Cos and epcnion which may CL (We)agree m sew,indemnify and keep harmless Ne City of Cupcnino against Z in or We oftcnusmit. bey in any way accrue against good City t.) z in eonsogwnco of be gaming of this permit. ^' APPLIC UNDEPTANDS AND WILL COMPLY WI ALL NON-POINT Issued by: Date SOURCE EGU I c ate Re-roofs newts o n .m actor Dau HAZARDOUS MATERIALS DISCLOSURE Type of Roof itl the applicant or future Wilding occupant sme or handle hatiodous material u defined by de Cupertino Muni .Chapter 9.12.and ted Health and Safety Code.Seen..255J2(a)+ /tea All roofs shall be inspected prior to any roofing material being installed. ❑Yu Y Dro Will the applicant fuullum building occupant sew equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove 7dw hnuranus air conuminanu u defined by be Bay Arca Air Quality Management all new m Is for inspection. Yes avereW me hararthes mates5.255ll ulrcments4.1.r .wdr 5oflhc Wilding ��of g:SafctyC ccium25N)5.23573and255J4.1undcmm�dmoti(tie Willingnot tine y a nwL mat it is my resragoodiby m..dl'y the occupant of Nerim a pdartuimusreco(acenlficseo(occupncy. SI atureofApplicant Date so11 �� All roof coverin s ro be Class "B" or better er sutharimd agent Dae g �C .� CITY OF CUPERTINO 4Z -= FURNACE/AC a 3 f Ap UPEkTINO PERMIT APPLICATION FORM APN # 3 �-Z 32— 03 O Date: 3 Building Address: 7 (ax Owner's Name: Phone#: i� 2- Y pw-- Contracto�: //�� // n�q hone: License#: c) r WAS Tl l ✓ CbKdl k v 4M 5 S- Contact: Phone: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential E31 Commercial ❑ /Z, For Residential Installations: Attic ❑ 151 floor ❑ 2nd floor❑ dhere to min set back requirement❑ or Commercial Installations: Replacement same weight Additional weight (structural calcs) ❑ Structural Calculat' require - ew installation ❑ New installatio lannin A rova a uired ❑ Cost of Pro j ct: _ Type of Construction: Occupancy tur r3 /S G� Strapped On P mi ❑ Bonded ❑ Sq.Ft. Floor At New Location ❑ Replacement ❑ Qt if li le 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 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 �� 72 , 27