03040062 (2) 'CITY OF CUPERTINO `x ' s
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BUILDING DIVISION PERMIT uc, ,TTRACTOR„XO MA�1t '
BrpLP15181DIgL3bTLAND DR AAA FURNACE & AIR CONDITI OTYCYCE03040062
RRAE'CHRISTENSEN 1712 STONE AVE ITg��A�10/2003
NE: (408) 293-4717 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT HIM
BLDO ELECT PLUMB MECH
O O O
app LICENSED CONTRACTOR'S DECLARATION JobDescrition
1 Ou 1 hereby aObm that I provisions licensed under provons of Chapter 9(commencing p
with Section 7001))ofDivht..3 of lite Business and PmfcWmu Codo,and my lkonx t-
in
a
m Lirot
cet eeindJ . REPLACE FURNACE FINALE®
y�� Licenx Class IY.g
Oak lunderuand my phnsshdll be used a public AxmN
t APR 1 6 2003
Licensed Pmressiom
OWNER BUILDER DECLARATION
I I hereby affirm that I am exempt from the Communes License Law rot the BUILDING
e D following reasna(Section 70013.Business and Profession Code:Any city or county
S3�i' which mqulms a Permit to etmurue,alter,borrow.demolish,or repair any structure
prior k its issuance.also mquims the applicant for such Permit to riles algned.utemmn
€< that W is licensed pumlant to the provisions of lac Contractor's U...I..(Chap=9 Sq.Ft. Floor Area $YY ldtion
$ (commencing with Suction'EMB)of Division 3 of me Business and Profmdnm Code)., YY
..
that he is exempt therefrom and the bull her the alleged exemption.Any 1.1.d on of
Seclon 7031.5 by any appllanl fon permit subjects the applicant to a civil Penalty of 3 6EN NOMISer 0 0 Occupancy Tt pe
not more than five hundred dolor($500).
O I,u moor or the property,or my onployce,with wages to chair wk compensation,
will do the work and the structure 1,not Intended or offered for AMC(Sec.70//.Bodnrss — H Ct10HS
and Prefesdons Code:The Communes Lion.raw dors ret apply to an comer of 303 - ROUGH M CHAN CAL
property who bu ods orimproveart
meon,and whodusssuch work himself or Wough his
ownemployaa,pnvldad thattuch improvement am not intended or offered for We.if. 304 — ROUGH ELECTRICAL
however,the building or improvement Is sold within ore yew of completion,the owmr-
bu0der will have dk burden or proving that he did not Mid or impmw for purpose or 505 — FINAL ELECTRICAL
sale')' 507 - FINAL PLUMBING
O 1.as owner of the Property am exclusively contracting with licensed eomraetere to
construct the project(Sec.70dd,Business and PmfusJons Code)The ConbRtort Ll- SOB — FINAL MECHANICAL
«rte Paw does not apply mar owner of property,who Wilds or improves themer.and,
who contracts for such projects with a contractor(.)licensed pursuant to the Consomme.
License Lew.
O lammemptooder Sec .Bit PCfmthlakason
137M
ee Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penally of perjury,one of she following declarations:
I haw and will maintain a Certificate of Conten.teff.m.um for WmIxesCopper.
lon,u provided for by Section 3700 of the Labor Code,for the performance of the
rk for which this permit Is hunts.
1 hew and will maintain Workefs Compensation Insunnce,as required by Section
of me labor Code,for tie performance of the work for which this Permit i.Issued.
yWorker's Compensation Insuranee artier end Policy number aha:
rrier. 0_�sA.l Polley No.: �Z
CER FICA OF EXEMPTION FRO O K'RS'
COMPENSATION INSURANCE
(This xcdern need not be completed If she permit I.for one hundred dnllan(SIM)
or less.)
1 certify tha In the performance of the work for which this permit Is issued,I&Full not
employ any yeomen in any munenn u to become subject to the Worker'Compensation
Laws of Calify/nice.Dam
App lice I 7w- s -
NOTICE APPLICANO It,of r making this CcniOcne of Exemption.you should
become mbjecl to the Worker's Compensation provisions of the Labor Code,you must
.,O forthwith comply with such Prevision or this Permit be domed revoked.
„Z„y CONSTRUCTION LENDING AGENCY
(r I hereby affirm that them is a construction lending agency for the performance of
the work for which mit permit Is Issued(Sec 3097,Civ.C.)
!y Q Lander's Name
z Lender's Address
U 0 1 cenify that I have rod this app ics ion and stsk that the above Infommlun Is
U. correct.t agree to comply with all city and county ordinames aM lute Paws milling to
O U Wining construction.and hereby sethorix mpmartaim or this city lYenmr upon the
ahtw-mentioned property for Inspection purpoods.
(We)agree to saw,indemnify and keep harmku the City of Cupertino against
ti n liabilities,judgments,casts and eapensos which may In any way seem against laid City
U,'Z in consequence of the granting of this Permit. j
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of AppllaR Date
HAZARDOO US MATERIAupi DISCLOSURE Type of Roof
Will tik a Cupertino
nsnoor future building Code.
hapt r9.1 o handle Health a material
u dcfinetl by aha Cupertltw Municipal Code.CNpter 9.12,and the Halm and Sanity
We.section25532()7 All roofs shall be inspected prior to any roofing material being installed.
El Yet fo
Will the applicant or future Wilding occupant sax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hvsrdous air conumimnts as defined by mc Bay Arta Air Quality Management all new materials for inspection.
Idess
istrio7
Oyu u
I have reed me hnuNm.mmridsmquimmenu un@r Chapkri95 of the Califon.
u Halm&Safety Code.S.eti.255(15.25533 uu125531.1 understand dm If aha Wilding
not currently haw a ktmn,that It it my responsibility to notify de occupant of dha
q �eents which puff he met prior in comma of a Certificate or occupancy. Signature of Applicant Date
corer or antnm9 agent eek All roof coverings to be Class "B"or better
WIT
CITY OF CUPERTINOFURNACE/AC
UPI�TINO PERMIT APPLICATION FORM
APN # Date:
sloo2 - - �o� o -o�
Building Address:
Own 's ame: Phone#:
Contractor: Phone: License #:
gh-ja Ad 0) - 00 4�,e 71
Contact-: Phone: Cupertino Business License#:
K,eo:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
U/ 4 CG
Residential ❑ Commercial ❑
For Residential Intallations:
Attic ElIst 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: Type of Construction: Occupancy group:
,Zino, o'a
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applic e 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
l BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elee Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE P umbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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