07010132 -.-77777 777777777=77777. 7 7. 77-7.
CITY OF CUPERTINO
BUILDING DIVISION PERMIT C� ]E�LC ®R IIYEQRMTIf�N
PERMIT NO.
BUILDING ADDRESS:
10892 CANYON VT-qTA TYR
T� PERMIT UE DATE
OWNER'S NAME:
LANE JAMES C ET AL 01/22/2007
SANITARY NO. CONTROL NO.
-IONS:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
40C LICENSED CONTRACTOR'S DECLARATION Job Description
t u r- 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
=UZ with Section 7000)of Division 3 of the Business and Professions Code,and my license is INSTALL NEW FURNACE AND A—COI L
y in full force and effec _
Z Licen 1 Lic.M
Contractor
Ez w Dam ARCHITECTS DECLAR TION
a .t
,< I understand my plans shall be used as public records
�yU
u I- Licensed Professional
C a
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
e which requires a permit to construct,alter,improve,dcmmlich,or repair any structure
n Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $2400
xF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y R S- that he is exempt therefrom and the basic for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 35602050. $N Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure isnotintendedorofferedforsale(Sec.70",Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Workces Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
JZ I have and will maintain Worker's Compensation Insurance,as required by Section
'"M of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Co pen auon lnsursn arricr and Policy num�er�fc;s
Carrier: tl K Policy No.: � 0���
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($I00)
or less.)
I certify that in the performance of the work for which this permit is issued.1 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
2 forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
Fr►CA- 1 hereby affirm that there is a construction lending agency for the performance of
fS! > the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Lender's Address
U C) I certify that I have read this application and state that the above information is
w r r correct.I agree to comply with all city and county ordinances and state laws relating to
rJ Ubuilding construction,and hereby authorize representatives of this city to enter upon the
above-menuoncd property for inspection purposes.
W
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City / v�
U Z in consequence of the granting of this permit. A0%0�.Date
r" APPLICANT UN S NDS NO WILL COMPLY WITH ALL NON-POINT Issued b):
SOURCE RE
Re-roofs
SignatureAppli =tor A Dam T Of Roof
MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes *No
11�� If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
❑Yes Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.[understand that if the building
does not cu ly ha a tens that it is my responsibility to notify the occupant of the
requiremc ich ust be prior to issuance of a Certificate of a �� Signaturc of Applicant Date
All roof coverings to be Class"B" or better
Owner or authorized a t Date
CITY OF CUPERTINO 0-10 L O l 39-.
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
,PN# Date: �7
3 - --<50 -a -a
Building Address:
Owner's N e: Phone#:
6 liq
Contractor: hone: License #:
`3 6
C act: Phone: Cupertino Business License#:
�a U�f'► 1 - J C'
Building Permit Info:
Bldg ❑ Elect E9--" P umb [I'— Mech -
Job Description
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1 St floor Z 2nd floor❑
Adhere to min set back re El
Ad requirement q
For Commercial Installations:
eplacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Required ❑
Cost of Project: Type of�struc:ion: Occupancy roup:
Strapped ❑ On Platform D— Bonded n Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if Fee Group
Applicable Fee ID Fee Description
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A'C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A'C Units<= 10, 000 cfm MECHANICAL
BREMRECEPT R;c tl, Switch& Outlets ELECTRICAL
BSEISMICRE Soismic Fee Res BUILDING
BSEISMICOM Soismic Commercial BUILIDNG
EPERMITFEE E_ec Permit Issuance ELECTRICAL
MPERMITFEE M ech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE B Jg Permit Fees BUILDING
BPLANCHK Y an Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING