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CITY OF CUPERTINO
DIVISION PERNIIT�1]TC
BUILP,ING
BUILDING ADDRESS:
PERMIT NO.
20183
OWNER'S NAME:
PERMIT ISSUE DATE
r0
AVE
SA CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
WATR HTR REPLCMNT
CJ D D D
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(10) of Division 3 of the Business and Professions Code. and my license is
in full force and effec Q 1 3 3
License Cl Li 8
Date Contractor
RCHITECTS DECLARATI N
I 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
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
License Law 9
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(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
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
ns Required Inspections
p
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
q
property who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such improvements arc 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.).
❑ 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 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 Worker's Compen-
_.ion, 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 Worker's Compensation Insurance carrier and Policy number are: 1
Carrier Na Aw/t US. PolicyNo.: Fot+�C441Si
CWHFICATE 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' 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
forthwith comply with such provisions or this permit shall be deemed revoked.
)
' CONSTRUCTION LENDING AGENCY
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.)
Lenders Name
Lenders Address
1 certify that 1 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
" building concoction, and hereby authorize representatives of this city to enter upon the
? above-mentioned property for inspection purposes.
" (We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
r in consequence of the of this
n C
granting permit.
+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued ty: Date V
SOURCE MQMArPNS.
->-140
/ • �
Re -roof —
Type Roof
Signature o pplicanUContracior Date
HAZARDOUS MATERIALS DISCLOSURE
of
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)?
[v�No
All roofs shall be inspected prior to any roofing material being installed.
C3 Yes
a room is installed without first obtaining an inspection, I agree to remove
ill the applicant or future building occupant use equipment or devices which
Will
t hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
,trio? /
❑ Yes G Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & SafetyCodc, Secdons 25505, 25533 and 75534.1 understand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
ts which must ty met prior to issuance of a Certificate of cupancy.
Signatul a of Applicant Date
a i
All roof coverings to be Class "'' or better
Owner or authorized agent Da
CITY Of
*7UPEIQTIN0
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Build-jing Department
JOB ADDRESS: q""
X183 N orl44trc if s c� din. t4}
PERMIM-5
Z�%�-�
-h S uw
PHONE # *08 93 04� 2$
-OVVNER'SNAME:
GENERAL CONTRACTOR: A ir 14 Pl6,cmi,
FAX #
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
Owner/Contra for Signature Date
SUBCONTRACTOR
BUSI:�TESS 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 for Signature Date
Cfoao�� -Sl
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN #
D/6 37 003
Date:
F" to �
Building Address:
2083 Ner Kewes+ alwe4eN.o A ?0017
Owner's Name: r
Phone #: (o j Q 3e 0 �2 a
Contractor:
Phone #: -4 v t , r e TV
r
A
Fax #:
Contractor License #:
Cupertino Business License #:
Pr A
n ..
Phone #:
Contact:
;kz FvY
Fax #:
Building Permit Info:
Elect 0 Plumb [� Mech E�t'
Residential Commercial
Job Description:
fu.rh acs r''-1°la ccri►er,,,f-
For Residential Installations:
Attic ❑ lsc 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: Type of Construction (Usage Class):
Strapped ❑ On Platform ❑ Bonded New Location ❑ Replacement
Pro'ect Size: Express [[} Standard ❑ Lar e 1:1 Major ❑
Valuation:
Green Building: Please complete relevant portio n of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index. C�l
tcevisea viiviivy
CITY Off' CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
FURNACE
FURN/AC
1 MCRAA
Commercial- Repair/Alteration/Add to
M
ea heating ap oiliance,refrigeration unit,
cooling unit,z.bsorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation o:' controls regulated by this
code.
1MCREPALT
Commercial 'or the repair of alt/add to
M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR
Commercial Install/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounteJ unit heater.
1 PGASCOM
Commerical for ea gas piping System
P
1-4 outlets
1BPGAS
For each gas piping system of 5 or
P
more per out. et.
IMCAPPVNT
Commercial for the install/relocate/ or
M
replacement of ea appliance vent
installed & n X incl in an appliance
permit.
1BCBSC
Cal Bldg Staidards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICO
Commercial Seismic
B
1 MRRAA
Residential F.epair/Alteration/Add to
M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1 MRSUSHTR
Residential I r►stall/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounted unit heater.
Ll
CITY OF CUPERTINO
FUR]vACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Descripl ion
Fee
Permit Type
Group
IMRAPPVNT
Residential f6- the install/relocate/ or
M
replacement of ea appliance vent
install & not incl in an appl permit.
FURNACE
FURN/AC
1 PGASRES
Residential f - ea gas piping system of
P
1-4 Outlets
1BPGAS
For each gas piping system of 5 or
P
more per outict.
1BCBSC
Cal Bldg Stan Jards Commission Fee
B
ALL PERMIT
I
TYPES
1BSEISMICR
Residential Seismic
B
1MECPLNCK
Mechanical Plan Check
M
IMFR=<100
Furnace Syst-,-=100k BTU install or
M
relocate ea forced-air/gravity type
furnace/burne:-, incl ducts/vents
attached to su(;h appliance up to and
include 100,000 Btu/h
1 MFRN> 100
Furnace Syst => 100k BTU install or
M
relocate ea forced-air/gravity type
furnace/burne:-, incl ducts/vents
attached to such appliance over
100,000 Btu/h
IEPERMITFEE
Electric Permit Fee
E
r
1 MPERMITFEE
Mechanical Permit Fee
M
/
IPPERMITFEE
Plumbing Permit
P
ITRAVDOC
Travel Docurrentation
B
1 BUSLIC
Business Lice ise
B