03050012 (2) CITY OF CUPERTINO °
BUILDING DIVISION PERMIT CONTRACTORkINFURMATION:
BUILDING ADDRESS: CONDITIONED AIR Y P.MITND03050012
i
OWNER'S NAME: 1701 LITTLE ORCHARD ST M`Mn`g`ffn2/2003
ildhOURAD ABDEL A ANT) VICTORIA
ONE: (408) 291-2220 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 I�
40p LICENSED CONIRAC7UR'SDECLARATION lob Description
�a 1 thereby affirm Nn 1 an licensed under previsions of Chapter 9(commencing F I N A L. D
m wiNSectlon70M)af Divlslon3ofdse Buainwand Pr fulnn Com
de, dmy Hmoscia
Mau omeaneerc 1.�a51 (p REPALCE FURANCE
Z Datence Clw Contractor
ARCHITECTS DECLARATION MAY 0 8 2003
'y5 s I understand my plana Mall he used as public records
'0`r3 LiaenmdProre,ainral BUILDING
OWNER-BUILDER DECLARATION
i�x I hemhy affirm Mat 1 am exempt fours the Canomurs umnse Law for the
yp0 following mamm.(Secdan II31.5,Business and Prefwinv Cade:Any city or county
which requites a permit to condma alter,borrow,demolish.or repair my structure
FZi
prior w its issuance.a1wrequires the applicam nor such Permit in rile a signed statement
p 0that he is licensed Pursuant to Ne provisions of Me Common's UccrowLaw(Chapter 9 Sq.Ft. Floor Area $2��tion
n,Sp$ (commencing with Sermon 7")of Division 3 of the Business and Professions Crack)or 4
3— that he is exempt therefrom and Me basis For Me alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects Meepp]icanno a civil onatty of 3 2VPWX 4er0 0 Occupancy Type
not mom than fin hundred dollar(M).
Q 1,u owner of Me property,or my employees with wages as Mein auto compenution,
will do the work and the swmumisnot brooded or offered for sate(Sec.7041,1.Business — ROUGH
and Prefwiov Cade:TW Comnomrs License law does nm apply M an nater of 3 0 3 - ROUGH HAN I AL ns
property who builds m improv thereon.and who doesauchwmk himself ormhreugh his
own employees,provided that such improvements an not Intended oroRerW for sale If. 304 — ROUGH ELECTRICAL
however,Me building or improvement is sold within one year of complexion,Me owner.
Wilder will have Me Which of proving that he did ret Wild or Improve for purpose of 505 - FINAL ELECTRICAL
tale')' 507 FINAL PLUMBING
0 I.as most of Me property,am eaclualvely eanuacting with licensed ronoacmu in
construct the project(Sm.7Wa.Business and Professions Code:)The Conbmmra U. 508 — FINAL MECHANICAL
cove law does not apply m an trader of property who Wild,or improves daemon,and
who contacts for such projects with a contacmr(s)licensed pursuant M the Conuactora
Lienee Law.
❑1 em exempt under Sec. .B d:P C for this mason
137�
wner Data
WORKER'S COMPENSATION DECORATION
1 hereby affirm under penalty of perjury,ane of the following declarations:
1 ban and will maintain a Cenifirnm of Consent M self-ivun,for WortrM1 Comi en-
ion,as provided for by Seeded 3700 of Me labor Code.for the performance of Me
rk for which this permit is issued.I ban and will maintain Workers Compewtion Insurance,u mpuired by Section
of Me labor cede,fo Me performance of the work for which this permitisissued.
Workers - uai -Ivvnnct artier aM Policy nu//nber are: /1 res �j �r--
nier. Policy Na.;-yp, lei 0� 3 3 Q (p
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(lbi smilen need not W completed ifft Permit is forst hundred dollars($I00)
or less.)
I eenty that in Me performance of the work for which this Permit is issued.I Mall not
employ any person in any manner as u in become abject to lW Worlums Compensation
Laws of Celifmrla.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you mould '
become subject to the Work es Componudon previsions of Me,Lather Code,you most
sZ foMwith comply with ouch provisions or this Permit shall be dmencel mwked. .
z'O CONSTRUCTION LENDING AGENCY
[..4 I Wmby aRrm that Men,is a construction lending agency for Me perrorm race of
a t>-t Me.,it for which%is permit Is issued(Sec.3097.Civ.C.)
40 Lm,cr'a Name
U z larder's Address
U O 1 comfy that I haw read this applic"on aM stem Mw Me show information is
LL^'. comma I grce to comply with all city and county ordinunes and state law relating to
O SV' building construction,and herebyauthome representatives of this city to an=upon Me
(i] above-mentioned pmpeny for inspection purposes.
gy (We)agree to an,indemnify and amp harmless the City of Cupertino against
fA liabilities,judgments.costs and eapenev which may In any way me=against aid City
U in consequence of the graining of this Parrott.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER GULATIONS. r'
✓AelMN4r !� Re-roofs G7 —}
Signature of ApplicmJC m V
Dam 2— a
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle huaNaua material
u defined by the Cupertino Municipal Code.Chapter 9.11,and Me Health and Safety
Cade.Section 15531(¢)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes bM
Will Me applicant or future Wilding aceupart use equipment or denims which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardnua air comeminanta u fined by the Bay Area Air Quality Managcmcm all new materials for inspection.
Disticx?
❑Yes u
than n,W the h uardous materials rcquiremems under Chapter 6.95 of the Califor-
nixH.1"Safety Code.Sectimw 15505,15533 and 25534.I understand that if de Wilding
MrM
s,win currently haw a amend, u it u my responsibility in m ify M,oempont of Me
requirements which must he met prior m ism Pon, or a Canincam artxcupmey. Signature of Applicant Date
wncr or rtharircd e t _xE'One roof coverings to be Class"B"or better
CITY OF CUPERTINO o
GFURNACE/AC
Y OF
CUPERJINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: d� 1` �C V Phone#:
Contractor: Phone: License#:
orJOb A"C►2.^ 8451 (o')_
Contact: � � Phone: Cupertino Bunsicense#:
Building Permit Info: 55
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description: uj
Residential 1/r` Commercial F-1
For Residential Insta ions:
Attic ( I I't floor 2"d 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:
Strapped ❑ On Platform El Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable 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
EPERMII'FEE 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
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