03060080 (2) I CITY OF CUPERTINO -�- ,=°" '�` %'' `�
BUILDING DIVISION PERMIT CQNTRAC QR INk'QRMATRO T .
BUILDING ADDRESS: GOSAL HEATING&AIR CONDITIID'03060080
OWNER'S NAME: 2679 CHERRY BLOSSOM :WAY P02MIT LSSU DA/710/2003
ANOU E b
NE: (510) 441-2318 SANITARY NO, CONTROL NO.
ARCHITEC17ENGINEER: BUILDING PERMITINFO
BLDG ELECTPLUMB MECH
I� o o t�
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
I hcmby of im,Net I am Itttmed oder pmviei0na of Chepmr 9 mommencing p
with Scdion lrxgry of Divuion3ordm a L and Profculone Code,andmyllcenuu
n❑ in full fou a eD 1. FURNACE CHANGEOUT & .ADD A/ 1�g p� {1 r�p1�j
,Rz LIccnu C7� 7 To. - ��B@9B^�9�E "
Dau -co."
om r
AR 5 D RATIO
duty
plans sha"bodud Mic..PhJUL 1 0 2003
h�
Licensed Professional
OWNER-exempt frDECLARATION
I0 f 1 ream .fano the 1 1. exempt from the Connector's o License Law for the
county BUILDING
02 folwhich
owing recon.permit
t 7xmmu5.Business and profession,Code:Anyrepair
y or county
S$ which its Wo•pemth re ennuruct,alar,improve,h pchnsh.ri uryig any statement_Its^ pram re its Women.purse requires ttohe thovisio s rd,of far tech permit re rile a cense Lrcd nommen,
< Wammencing wit pursuant the of Division
of the eBusi,ess LicenulawsCode)9 Sq. Ft. Floor Area $,f�®l9gion
g?$ $ (commencing pt Section7000)and
of Divisionr the
alleged
exemption.
Anand y
eCtion Of
c�� Wat he LL exempt therefrom and the bole for the alleged esemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant in a civil penally of 3 X819 6I6 akr 0 0 Occupancy Type
trot moa than five hundred dollars(5500).
0 I.u ownv of the pmpvty,army employe with wages u thele sole eompenudon,
willdr Mework,and theswetum is not Intended orreffernl forsam(Sm.7044,Business —
and Professions Codo:The Conductor's Liam Law does ant apply re an owner of 304 - ROUGH Its
who builds or improv Wesson,and who does each work himself or through his
own employees:provided tile,such lmprovementa ue not Intended oroffered for We.If. 505 — FINAL ELECTRICAL
however,We budding or improvement is said within one year of compledon,the owner.
builder will hue the bum=of proving Met he did not build or improve for purpose of 508 - FINAL MECHANICAL
sale.).
El 1,u owns,of du property,am exclusively contMing with licensed contractor,to
construct Ile project(Sec.70al Business and Prometheus,Code:)The Contracen's U.
come Law does not apply to an owner of property who builds or Improves(hereon,and,
who contracts for such projects with a eontrialo(s)licensed pursuant m the Convector'. '
License law.
❑Iamexemptunder Sec. ,BRPCIcxmisrcasan
Owner Data
WORKER'S COMPENSATIONDECL RATION
1 hereby affimt under penalty of perjury one of the following decimations:
ave and will maintain a CaNlmme of Consent to ulfduure for Workers Compen-
utiti ,as providrA for by Section 3700 of We labor Code,for me performance of the
work for which this permit is issued.
❑1 have and will maintain Warkeh Compensation Insurance,as acquired by Section
3700ofthelabor Crel the peremaNxe f(he work forwhich this permit is broad.
My orkefa Compenullanlmnrcoes ' rad Polity number ma:
er. Hey Nr,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisucdon rcc0 per be completed if the Permit is(marc hundred dollen(SIOf)
or Ions)
1 certify Wet in the performance of the work for which this uhnnit is issued.I shall not
employ any person in any manner an as w becomesubjecno We Workers Compensetlon
Law,of CHm
ifola.Date
Applies..,
NOTICE TO APPLICANT IL after making this Certificate of Exemption.you should
become subject re the Workora Compensation provisions of the labor Cads,you most
Q forthwith comply with such pnwieinns Or this Permit shall be deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
1 hereby affirm the,there its construction k..ding agency for the Performance or
0: We work Na which this Penni,a!
lanmes Helm LLsnsd(Son.3197,Civ.Cd
1 A
7 ,Z Lendaes Address
J Q I cenify that I have read this application and mu that the starve information is
U. F torten.l agree to comply with all city and county ordinances and sum laws relating to
�U building construction,and hereby lotion.reperem.avcs of this city to enter upon the
C
.how-mentioned property for inspection purposes.
(We)ogee in ave,indemnify and keep harmless Bre City of Cupcnino against
,rr Cl) Imbilitmejudgments.comenderpcmu whichmayin anyway accrue aguu,uid City
J Z in consequence of die{undng of this permit C
— APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S OUaRldCreE7lrcAaT10N5_.j� /
Re-roofs
ppm
HAZARDOUS MATERIALS DISType of Roof
Will,le applian,or furans building occupant Yore ar handle huallou material
u defiled by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
a k.sadona5s3z(a)7 q All roofs shall be inspected prior to any roofing material being installed.
�Yce fTNd
will the aPplicut or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haurdnm air conuminanu u defired by the Bay Arta Air Quality Management all new materials for inspection.
District? ✓�/J �f
❑Yes u ���.iii? C
Iheve real the hasaNnusmateriale mquiremcnu under ChaPmr G95 arthc Califon �� A
nee Health titSalcty CaM,Scctions25R13,25533 and 25531.1 undcrstend Ihuifine huildin{ // /1
dreg no,currently hove s tenant,Nat It u my respomihi re.11ythe acupsa,.1the
require u ichmud be rest w issuance Ora coni am of Occupancy. Signature of Applicant Date
r,aamarixm agent 6Dmc All roof coverings to be Class "B"or better
CITY OF CUPERTINO
C FURNACE/AC o 3 6,0
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
/ia/ y3
Building Address:
Owner's Name: - 7�"�o v S Phone#: isc�-,a S'163 73
Contractor: /oL y V � Phone: c, io K I 23/2' License#:
Contact: �'f�S/71� Phone: go y 4 l 13 (S' Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech C$7
Jobescription:
n--c t- Cc e tR 4 0 % Yr� >)-o 79 J4-
Residential P Commercial ❑
For Residential In fellatio :
Attic El 1"floor Un2"d floor❑
Adhere to min set back requirement El
For Commercial Installations:
Replacement sam weight—Q\Additional weight (structural calcs) ❑
Structural C ations required dor ew installation ❑
New instal tion Plannin Approval Pequired ❑
Cost of P ojec So V Type of Construction: Occupancy group S
Strapped latform ❑ Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Appli 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
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 I BUILDING
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