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07050005 CITY OF CUPERTINO BUILDING DIVISION PERMIT C NT INF:oIM� Io�t -- PERMIT NO. BUILDING ADDRESS: OWN A CONDITIC)NING F.' NE AVE S®i§TAlD(1J0.2 0 0 7 CONTROL NO. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH C� 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing v with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and life t 9RCH�MCTS REPLACE FURNACE, ADD 3 1/2 TON A/C y z License Class Lic.M w Datc Contractor DELLA A 1 understand my plans shall be used as public records Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the ofollowing reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit t h construct,alter,improve,demolish,or repair any structure ti prior to its issuance,also requires the applicant for such permit to file a signed statement e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q.Ft. Floor Area Valuation (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 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 APN Number Occupancy Type not more than five hundred dollars($500). 0 I,as owner of the property,or my employees with wages as their sole compensation, 34233003 . 00 will do the work,and the structure is notintended 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.). 0 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 docs 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. 13, I am exempt under Sec. B&P C for this reason Owner Dale WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Workers Compen- -ton,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 I 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 Worker's Compensation I�Lsy[ance carrier and Policy numbers n' Carrier�(, CERTIFICATE G r// PolicyNo.: f� CE TIFICATE OF EXEMPTION FRO ORKERS' 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,I shall not employ any person in any manner so as to become subject to the Workeri Compensation Laws of California.Dale Applicant NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. C) ''" CONSTRUCTION LENDING AGENCY :4 1 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.) ZLenders Name Lender's Address 1 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 jbuilding construction,and hereby authorize representatives of this city to enter upon the above-mentioned 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 `per Z in consequence of the granting of this permit. Dale APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON-POINT Issued by: SOU �j E REGULATIONS. C41_/All.e!la-L— .�� 02 Re-roofs /c-�- grig aturc of'Applicam/Contraefor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazxdous 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. 0 Yes If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant oturebuilding occupant use equipment or devices which hazardous air conga tenants as defined by the Bay Area Air Quality Management all new mz terials for inspection. -„strict? 0 Yes I have mad the heard materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Codc,Sect ns 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the require nts which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date � %rte les -101"10,2- All roof coverings to be Class"B"or better O nauth zeer or gent Date CITY OF CUPERTINO i � FURNACE/AC�UPlot, kTINO PERMIT APPLICATION FORM 5 APN# �jl� D� �i Date: Building Address: Owner's Name: Phone#: C tractor: Phone: License #: , r Contact: Phone: Cupertino Business License _ #: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech FSI Job Description: Residential P Commercial ❑ For Residential Installations: Attic ❑ 1St floor ' 2nd floor❑ Adhere to min set back requirement(� 'Vor Commercial Installations: Replacement same weight ❑ Additional weight(si ructural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction: Occupancy group: Strapped 0 On Platform ❑ B4ded CI Sq.Ft. Floor Area: New Location ❑ Re lacement Qty. if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Furnace MECHANICAL BREMACOVER AJC Unit> 10,000 cfin MECHANICAL BREMAIRHAN PJC Units<= 10, 000 cfin MECHANICAL BREMRECEPT F.ec tl, Switch & Outlets ELECTRICAL BSEISMICRE c eismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE E;lec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE E,ldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BPGAS Gas Piping System Fee PLUMBING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue Cupertino CA 95014 F Telephone(408)777-3228 CITY OF Fax(408)777-3333 'MkTINO Building Department JOB ADDRESS: PERMIT o L �^ Our c OWNER'S NAME: 4 r PHONrE # GENERAL CONTRACTOR: ,9 �w� FAX # I am not using any subcontractors: Si;;nature Date Please check applicable subcontractors and 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 A-"l Owner/ ontractor Signature Date