07020078 CITY OF CUPERTINO
BU1LDINid DIVISION PERMIT C���.GTC'/R I�UI�MATIf��1 .'
BUILDING ADDRESS: PERMIT NO.
18871 TILSON AVE SOUTH BliY REFRIGERATION 07020078
OWNER'S NAME: PERMIT ISSUE DATE
THOMAS SCHAPP 1014 MORSE AVE ST
)NE: SANITARY NO. CONTROL NO.
(408)26'-4503
ABUILDING PERMIT INFO
RCHITECTJENGINEER:
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is INSTALL NEW A/C 3 TON C ONDENS OR & COIL
y in full force anes
License CI _ Lic.N
t- Date contractor &N,4*
a ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
�yU
U.y Licensed Professional
y< OWNER-BUILDER DECLARATION
< I hereby affirm that I am exempt from the Contractors License law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
`e$04 which requires a permit to construct,alter,improve,demolish,or repair any structure
?Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q.Ft.Floor Area r Valuation
I-- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3 6 9 0
u g§ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of �l Number Occupancy Type
not more than five hundred dollars(S500). 37516039
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for workeescompen,
sation,as provided for by Section 3700 of the Labor Code,for the performance-of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My W L�a,JCC/�/mm�pfensatuou Insurance carrier and Policy number am:
CERTCarrieGk.rY ITE OF EXEMPTION FROM WO
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z— CONSTRUCTION LENDING AGENCY
t+4
+ 1 hereby affirm that there is a construction lending agency for the performance of
C4> the work for which this permit is issued(Sec.3097,Civ.C.)
aA Lender's Name
a z Lender's Address
U 0 I certify that 1 have read this application and state that the above information is
LL►-' correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
LL (Wc)agree to save,indcmn'y and keep harmless the City of Cupertino against
liabilities,judgments,costs and a rases which may in any way osseus against said City
U Z in consequence pNhe granting this permit. Date
APPLICANT DE N `AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR A
134 A "t
7 Re-roofs
Signa ofApplicant/Contractor 9,Dae Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstom or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)? All roofs ihall be inspected prior to any roofing material being installed.
C]Yes
Will the applicant or future building occupant fisc equipment or devices which If a roof i;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for ins eC on.
District?
❑Yes ❑UiK
I have rfad the
hazardoqu"em rider Chapter 6.95 of the Califor-r5v
niaHcaltb& ctyCode,Seco s2 5,2re533 and4a �r
/y
does not cunfndy ha n 1 it is my rcsponsihiIity to notify the occupant of the
rcyui men which m rte t p or to is:nonce of a Certificate of Occ panty. Signator of Applicant Date
" v All roof coverings to be Class"B"or better
OwncU authorized agent I 162tc
CITY OF CUPERTINO ®-7O?-M-7g
FURNACE/AC
CUPERTINO PERMIT APPIJICATION FORM
APN# Date:
t)39 /y o7
Building Address: II
Owner's Name: P �e#:
U0,zu :i
Contractor: rlJ Phone: /� License#:
�1 Gc i ct 17GVi '7 40 �V 7-x/.50?j 2_o 3 0
Contact* 61 Phone. Cupertino Business License#:
C(O S s- V-?-2 Z ZL:;> 7/
Building Permit Info:
Bldg ❑ Elect A Plumb ❑ Mech
Job Descri tion:
Residential �b Commercial ❑
For Residential ations:
Attic � 1"floor 2nd floor❑
Adhere to min set back requirement Ed
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Re uired Q
Cost of ProjeAt: Type of Constriction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded I:1 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
BREMAHMAN 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 BUILDING