03060123 (2) CITYOFCUPERTINO
BUILDING DIVISION PERA'IIT ��,xl, �QR INFUXtMA'TIQNh
BUIIAIND ADDRESS: PERMIT NO.03060123 3060123 PERMIT ISLjBDA}$
OWNER'S NAME: 8/2 0 0 3
ME; SANITARY NO, 1' CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo
LICENSED CONTRACTORS DECLARATION IbDescri tion
1 hertby affirm NoP
Nal I Am licensed under provision of Chapter 9(commencing
with UW Section?�11)of Division 3 of the Rus and Profeulou Code.and my license is
L enseclas1>0 > �QiQS�/�F� FURNACE/AIR CONDITIONING
g2
License clew `--7 t7 ..
bQQ, Date ^, can r CONTRACTOR: JUMP CONSTRUCTION
ARCIVTE
� IuniddwodmypIsm."IbcuAuAeEu ublicrec� �� ITA II /cal �2lrRj
L uu�ot tttttt���t; Licensed Professional
Itlt��GSC I♦-w IL..1!
OWNER-BUILDER DECLARATION
f 1 hereby affirm that I am exempt from the Contractors License U.for the JUN
I1.1 2 C 2 3
00 following muon.(Section 7031.5.Business and Profession Code:Any city m county - JVIV J
swhich requlms a Permit to construct.alter,hopmve,demolish.or repair any mucmm
prior it)its issuance.also roputrae the applicant for such Permit 1.RleaalgmdI statement ���
< that he is licensed pursuant to the prevision of the Concuv'e License Law(Chapter 9 Sq. Ft. Floor Area al
y O w(commencing with Section of Division 3 of the Business and Pro(nsions Code)or
Q $ Nal he is except therefrom and the basis for the alleged exemption.Any violation of 3800
Section 7031.5 by Any Applicant for A permit mbjecu the applicant to a civil penalty of APN Number Occupancy Type
rot mom t1m five hundred dollars(5500).
❑I,uowrmr order propeny,mmy wploym with wguuthevmte eompenadan, 32651010 . 00
wed do mcwork.and thaaUlnelure 4 oat imm�ded oroRertd fm Wa(Sec.IMa,Business R
and Profcadous Cade:The Convam es Lusums Law don non apply w An owner of 301 - ROUGH
eopegylr4 nsDGgc[ions
proparty who Wilds or improves thern,and who doessuch wank himselfor Waugh hisLUM N
own cmployea,provided that such improvements;are not intended ororterea for sale If, 303 - ROUGH MECHANICAL
however.me building ar impmvemcnt is sold within one year of completion.Ne...
builder will have the burden of proving last he did not Wild or Improve for Fort.of 304 - ROUGH ELECTRICAL
Asia')' 505 - FINAL ELECTRICAL
❑1,As owner of me property,am exclusively contracting with licensed contractors e
construct the project(Sec.70sa,Business and Prornsion Code:)The Commumues Li. 507 - FINAL PLUMBING
cane Law don not apply to an owner of property who Wilda or improver themes,and 508 - FINAL MECHANICAL
who contracts for such projecs with a comacter(s)li=nued pursuant as the Convectors '
License Law.
I]lIameam/pt�um rSec. .B&PCfmorismuan
Ow 1Ipcni .
WORKER CGMPIFSATIOrf QWJARATION
1 hereby aRism under pealtY o(perjury aro of the fallowing deelandon:
I have end will meinW n a Cervfinm of consenuo self-alum fm WerkoraConpen-
lion,as pevided fm by Semme 3700 of the Labor Code,for the perfmmance of Ne .
were fm which thio permit is issued.
❑1 ban and will maintain Workers Compensation Insurer=,As required by Section
3700 of the Labor Code,for the perfon manse of the wore for which thio permit Is issued.
My Workeh CnmPensadon Insure nmim ma P licy number am:
C mer: No.:
CERTIFICATE OF EX ON FROM WORKERS'
COMPENSATION INSURANCE
Mussoodon need not be completed if be permit is ferrous hundred doHms(SIM)
or Icsa)
1 certify that in the petformame of the work for which thia permit Is issued.I ahell me
employ any person in my manner An u to leWme subject to the Woracts Gampenution
Uwe of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cce iftnm of Exemption,you should
become mhjmi le the Wavers Compensation provisions or me Labor Coda you most
70 forthwith comply with such provisions as this permit shall the doomed mvnked.
i CONSmUCnON LENDING AGENCY
I rear which
that them is construction 30 lending7,Ck,sjenry for me per(urmensm of
Y, W work fur which phis permit is iu=d(S=.J097,Civ.C.)
YQ Lender's Nanta
Z Lcnderi Address
;)Q I certify that 1 have mad anis application and state that the above information is
1 (r•' correct.I agree to comply with all city and county mdinanco and sate law miming to
C.) building construction,and hereby authodm mpraanWivm of this city to enter upo)the
yabove-(We)A ed to ertysave for inspection apump ha l
(We)mgr=w ave,indemnify and lump ha,in An Ire City of Cupertino egtiel //
n Ilebiliryspury�n,Judgecnm.eous andcxpeasn which may in Any my ancstm agunn said City '
of the
of this
J z APPCICANfcUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER LATION3.
2-46-� -o Re-roofs
S' nature pp ietaXon or Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant see or handle he oats materitl
As defined by the Cupenino Munictp Code.Chapter 9.11,and the Health and Safety
ode,seeliamzss3z(e)7 All roofs shall be inspected prior to any roofing material being installed.
Y= o
7pi.wWill the applicant or future Wading mcupant on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air conamimms atglefined by the Bay Area Air Quality Management all new materials for inspection.
ner
❑YesI have madme huardws mamrils tequiremcnu under Clupmr 695 of me Califor.
Health h SomyCedc,Sotioe 75505.25533 And 25534.1 understand asl it me Wildaj
n MI currently have•tenant.that it's my maomibility m redly the metmant of t e
immensw ihmunkmetpnorwW =usaahCenifcim of Oceignature of Applicant Dale
ar,at N.ad sen, 0,8^� All roof coverings to be Class"B"or better
I
GQ CITY OF CUPERTINO
FURNACE/AC 03b�o/a3
CUPEkTINO PERMIT APPLICATION FORM
APN# 30?� �s/_�/� Date: (0_ I _ os
Building Address:
O S I - C0WT-i u A `ISO 1 !•
Owner's Name: Phone#:
SI /VIN 0011 ,102, - -73 -30 3
Contractor: Phone: License#:
SUrn COuS+r -- N yo y l • 29s4 65 -I
Contact: Phone: Cupertino Business License#:
,3ReS 1 (4)01feNbAr w yo yq '2 qLT
Building Permit'Info:
Bld ❑ Ele Plumb ch
Job Description:
2cv9 r?- c_
Residential Jr Commercial ❑
For Residential Installations: ❑
Attic Clf I" floor LJ 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 ro' t: p Type of Construct' n: Occupancy gro :
Cost ro�t.,
i
Straped LJ On Platform ElBonded El Sq.Ft. FloorA�
New Location I] Replacement
Qty. if
Applic0le. 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
PP.ERMITFEE Plumbing Permit Issue PLUMBING .
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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