07080115 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING DRESS:
113AD2 HUNTERSTON PL VALLEY HEATING & COOLING 0708001
PERMIT ISSUE DATE
OWNER'S NAME:
ZALUSKY ROBERT L AND 1171 N 4
SAN AR CONTROL NO.
OkT T f-LT LST TAT 7h
(408) 294-6290
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION
Job Description
O
[= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section 7000)of Division 3 of the Business and Professions Code,and m license is REPLACEMENT l�F AIC AND FURNACE
o• in fulF5��ARCHJTECrS
r2
nLic.#Contractor DECL A O
� 1 understand my plank shall be used as public records
U
F- Licensed Professional
FW—
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law or c
0 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
which requires a pe(mit to construct,alter,improve,demolish•or repair any structure
N prior to its issuance,also requires the applicant for such permit to rile a signed statement SFt.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
o (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $12716
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 3 6 2 2 2 0:'7`PN Number Occupancy Type
not more than five hundred dollars(3500).
1,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
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.).
[11.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 Contractoes
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 Workers Compen-
sation,as provided for by Section 3700 of the Labor Code•for the performance of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
37 of the Labor Code,for the performance of the work for which this permit is issued.
My orker� ;mpeasallon I unnce carrier and Poli her are,
Carrier Polity N..
CERTI CATE OF EXEMPT70N FRO WO CER '
COMPENSATION INSURANCE
((his section need not be completed if the permit is for one hundred dollars(5100)
or less.)
I cenify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject io 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
0 CONSTRUCTION LENDING AGENCY
a I hereby affirm that there is a construction lending agency for the performance of -
the work for which this permit is issued(Sec.3097,Civ.C.)
a QLendei s Name
4 z Lender's Address
C) I certify that I have read this application and state that the above information is
—' 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 ahovc-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
y liabilities,judgments,costs an zpcnses which may in any way accrue against said City
z in consequence of the g of this permit. Date !JY
APPLICANT U ANDS AND WILL COMPLY WITH ALL NON-POINT Issued b'r:
SOU R
Re-roofs
Signat of Appl' t/Contractor Vate
HAZARDOUS MATERIALS DISCLOSURE Type of:Zoof
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
Cole,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
0y No
Will the applicant or future wilding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new i naterials for inspection.
District?
Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not cu ave a tenant,that it is my responsibility to notify the occupant of the
require mel ' rtoissu ficatcof cupan . Signatur-,of Applicant Date
All roof coverings to be Class"B"or better
0 cr or oriicd Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
''UPEkTINO
Building Department
JOB ADDRESS: / PERMIT #
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
i tore Date
Please check applicable subcontractor an complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
r/Contractor Signature Date
CITY OF CUPERTINO
-
--FURNACETAC -
CUPE�,TINO PERMIT APPLICATION FORM
// � --� Date:
APN# '� lam' �
Building Address:
Owner's Name: Phone
Contractor: License#:
Contact: Cupertino Bu5i ess License #:
i
Building Permit Info:
Bldg ❑ Elect L � Plujnb COY' Mech Cg-'
Job Description:
r'Q p
Residential Commercial ❑�
For Residential Installations:
Attic ❑ 1St floor ❑ 2nd floor❑
Adhere to min set back requirement B�
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 Constriction: Occupancy group:
Cc,
Stra ped On Platform BB ded Sq.Ft. Floor Area:
Ld'
New Location ElReplacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin 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
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE BldgPermit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING