09020045 CITY OF CUPERTINO t^r
BUILDING DIVISION PERNIIT *� � � � �
PERMrr NO.
BUILDING ADDRESS:
10166 MC LAREN PL AAA FURNACE & AIR
OWNER'S NAME: C OND I T I ON I NG pERMTr L56UE DATE
A 9 9 CONTROL NO.
INE:
(408) 293-4717
BUILDING PERMIT INFO
ARCHITEC-r/ENGINEER: BLDG ELECT PLUMB MECH
u O Z LICENSED CONTRACTOR'S DECLARATION Job D6SCnptlOn
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z.:
with Section 7000)of Division 3 of the Business and Professions Code,and my license is RE P LC E X S TNG FURNACE
H in full force an f Co �7 4
j v�2 License Lle•x
-� Date !C9— Contractor >7 OL Ud{'_1NZ
ARCHITECrSDECLARATION
I understand my plans shall be used as public records
7yU
O y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
co following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct alter,improve,demolish.or repair any structure
u—"'
—H prior tp its issuance,also requires the applicant for such permit In file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3283
> .. that be is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars(M). 3 162104:6 . 00
0 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 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.).
0 1,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 comractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec B&P C for this reason
OwnerDate
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 Worker's Compcn-
,lion,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 Workees��c�o�m//pee�nsation lnsuranc carrier and Policy number are:
Carrier.54-1If 1 �Lf rt, Policy No.: 7 1 3 Sra 9 L'O
CERTIFICATE OF EXEMPTION FROM WORKERS'
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 Workers'Compcnsatian
Laws of California.
iaDate
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 CONSTRUCTION LENDING AGENCY
E.t CA I hereby affirm that there is a construction lending agency for the performance of
p(> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
az Lcndees Address
V 0 I certify that 1 have rad this application and state that the above information is
LL"4 correct.I agree to comply with all city and kcty ordinances and state laws relating to
0 Ubuilding conswction,and hereby author' ntadves of this city to enter upon the
Wabove-mentioned property(or'nape 'o a (We)agree to save,inde ify mless the City of Cupertino against
liabilities,judgments,coals an ex which may in any way accrue against said City
U z in c L
of granU of permit Date L
►'� LICARSTA AND WILL COMPLY WITH ALL NON-POINT Issued Iy:
SO RCEIONS.
— _OfRe-roof —
at nfnpphan ontractor Da1c T of Roof
HAZARDOUS MATER' 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 rooi's shall be inspected prior to any roofing material being installed.
0 Yes PIT'fo
If a foo�-
is installed without first obtaining an inspection,l agree to remove
Will the applicant or future building occupant use equipment or devices nt which all new materials for inspection.
it hazardous air contaminants av defined by y Area Air QualityMance amc
.strict?
0 Yes ElNO
1 have read the hazardous in ri quiremcnts under Chapter 6.95 of the Califor-
n' afcty Code,Sectio .25533 and 25534.1 undcrstnrtd that if the building
,Ildt curre tly have a tenan it is my responsibility to notify the occupant of the Date
aremquienta hick must be met 'or to issuance or a Ccnifiate of occupancy. SignatU e Of Applicantt AAll roof coverings to be Class" or better
or authorized agent Date
,
CITY OF CUPERTINO
FUR1gACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Ow er'sName: Pone#:
Contractor: A A � ,0QCr ru,lo N VAC- p,)C• Phone#:
F41 rGC
Fax#: 40-Ogg 3 -(v-n 1
Contractor License#: -7(0 43 /C 20 Cupertino Business License#:
Contact: `-7 j —('Q to 2e Phone#: 4-CO ol� 3- Ll
Fax#: - vtr'1 42, -7`1 1
Building Permit Info:
Elect FQ--"' Plumb ®-�' Mech
Residential Commercial
Job Description:,-Re jjis(! e E X;S4-,1r,e, F-L,.r'),3CA C.e_
For Residential Installations:
Attic ❑ I" floor 2°d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: '3 'Zg3:C)() Type of Construction (Usage Class):
77 V-0
Strapped On Platform Bonded New Location LJ Replacement
Project Size: Ex ress � Standard ❑ Large ❑ Major❑ _
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index. �—
Revised 01/07/09
CITY OF (;UPERTINO
-a FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Rel)air/Alteration/Add to M
ea heating appliz.nce,refrigeration unit,
cooling unit,absurption unit,or ea
heating,cooling,,Lb sorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliznce,refrigeration
unit,cooling unit,VAV boxes,
absorption unit c r ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heate-,recessed wall htr, or
floor mounted uiut heater.
1PGASCOM Commerical for -.a gas piping System P
1-4 outlets
1 BPGAS For each gas pip.ng system of 5 or P
more per outlet.
IMCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ incl in an appliance
permit.
1BCBSC Cal Bldg Standa-ds Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential Repz.ir/Alteration/Add to M
ea heating appliznce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or _
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heate-,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO FEE 'SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 MRAPPVNT Residential fir the install/relocate/or M
replacement of ea appliance vent
install ¬ incl in an appl permit.
FURNACE FURN/AC
1PGASRES Residential fir ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
113SEISMICR Residential seismic B
1MECPLNCK Mechanical flan Check M
1MFR=<100 Furnace Sys1 <=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to s ich appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Sysi > l 00k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to s ach appliance over
100,000 Btu,'h
1 EPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical -?ermit Fee M
1PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business Li<-ense B
M.Indoor Air Quality and Finishes INPUT
Resources IAQ/Health
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes.
3.Use Low/No VOC Adhesives31AQ/Health pts y=yes 0 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes p
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes p
10.Install Whole House Vacuum System 3 IAQ/HealthY=Yes
is
P p
N.Flooring
1 1 1
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes p
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts p--yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 1401 130 57
Total Points Project Received:
01 0 0
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.D4protected.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF
-UPE�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: PERMIT # v L�
IMC LQ r �(
OWNER'S NAME: ►, PHONE # -
GENERAL CONTRACTOR: jQ20dov C , FAX #
I am not using any subcontractors:
Signature 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
Owner/Contra r Signature Date