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09030057 CITY OF CUPERTINO BUILDING DIVISION PERT • MIPERMIT NO. [OWNER'S L-APM.TM-F. S: 30097 DR ATLAS—TRILL pERMTf ISSUE DATE SA CONTROL NO. PHONE: BUILDING PERMIT INFO ARCHPTECT/ENGINEER: BLDG ELECT PLUMB MECH FURNACE REPLCMNT C7 D 0 u o Z LICENSED CONTRACTOR'S DECLARATION lob Description VI hereby affirm that I am licensed under provisions of Chapter 9(commencing y with Section 7000)of Division 3 of the Business and Professions Code,and my license is n'<y in full force and effect 6 j Z Liven CI L n Dam_ n�Contractor RCH1TECf'S DECLARATION I understand my plans shall be used as public records m< �yU i C y Licensed professional. OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's 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.demolish,or repair any structure 43" prior to its issuance.also requires the applicant for such permit to rile a signed statement S Ft.Floor Area Valuation Z< that he is licensed pursuant to the provisions of the Con tracwr's License Law(Chapter 9 q YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Z3 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 five hundred dollars($500). ❑1,as owner of the property.or my employees with wages az their sole compensation, Required Inspections 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 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.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions buildsim roves thereonsand. Li- cense Law does not apply to an owner of propertyP who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law' B&P C for this reason I am exempt under See Owner Date WORKER'S COMPENSATION DECLARATION 1 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 in airier and Polity number are Cartier' ( ,C � —Policy No.: t CERTIFICATE OF EXEMPTION FROM ORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(S 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 az to become subject to the Workcri 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 ,J z forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY H 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 = Z Lender's Address U 0 I certify that I have read this application and state that the above information is cored I agree to comply with all city and county ordinances and state laws misting to 0 V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes >.4 (We)agree to save,indemnify and keep harmless the City of Cupertino against ,Hy liabilities,judgments•costs and expenses which may in any way accrue against said City C.>z inconsequence of the granting of ' permit. Date 7 16 U �+ APPLICANT UN COMPLY WITH ALL NON-POINT Issued by: SOURCE R Re-roof. of Applicant/Contractor °are T of Roof HAZARDOUS MATERIALS DISCLOSURE YPe Will the applicant or future building occupant store or handle harardous material az defined io the Cupertino Municipal .Chapter 9.12,and the Health and Safety Code,Section he Cup)? All roof shall be inspected prior to any roofing material being installed. 0Yes 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 -tft hazardous air contamin��No by the Bay Area Air Quality Management all new materials for inspection. strict? Ih ya 1 have read the hazardous materials requirements under Chap icr 6.95 of the Califor nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building- doesnot currently have a that it is my responsibility to notify the occupant of the Date reyui ts which m ficatc par+ // Ilan:e of Applicant = 6C� All roof coverings to be Class'V'or better Da Ow r oared agent te 0903�0�� CITY OF CUPERTINO FUWIACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # _ Date: _ O O 00 Building Address: Owner's Name: Phone#: Contractor: Phone#:L�(o <�,e Z L, Fax#: -Gam Contractor License#: Cupertino Business License#: &T� 1 : L( 2 Contact: Phone#: l d �,4f — w- A—'2 lir Fax#: Building Permit Info: Elect©/n Plumb [�`� Mech Residential Commercial ❑ Job Description: For Residential Installations: 1St floor 2"d floor ❑ Attic F1 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): C>0 C7 Strapped ❑ On Platform ❑ Bonded New Location Replacement Project Size: Express El'-- 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 CUPERTINO -` FURNACE/AC CUP TYOf O FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1MCRAA Commercial-Repair/Alteration/Add to M ea heating applian;e,refrigeration unit, cooling unit,absor)tion unit,or ea heating,cooling,absorption 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 appliarce,refrigeration unit,cooling unit,"IAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of con-xols regulated by this code. 1MCSUSHTR Commercial Instzll/Relocate ea M suspended heater.recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1 BPGAS For each gas pipi Zg system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed &not ir.cl in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Sei,,mic B 1MRRAA Residential RepEir/Alteration/Add to M ea heating appliz.nce,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,;tbsorption or — evaporative cooling system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Instccate ea M suspended heater,recessed wall htr, or floor mounted unit heater. CITY 01' CUPERTINO 52, FURNACEAC CUPEkTINO FEE SSEHEDULE Quantity Fee ID Fee Description Fee Permit Type Grou IMRAPPVNT Residential for the install/relocate/or M replacement of ea appliance vent install &not _ncl in an appl permit. FURNACE FURN/AC 1 PGASRES Residential for ea gas piping system of P 1-4 Outlets 1 BPGAS For each gas piping system of 5 or P more per outlet. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Residential Seismic B 1 MECPLNCK Mechanical F Ian Check M 1MFR=<100 Furnace Syst<=100k BTU install or M relocate ea fcrced-air/gravity type furnace/burner, incl ducts/vents attached to such appliance up to and include 100,00 Btu/h 1 MFRN>100 Furnace Syst> l 00k BTU install or M relocate ea fcrced-air/gravity type furnace/burnor, incl ducts/vents attached to such appliance over 100,000 Btu/a 1 EPERMITFEE Electric Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Pe:-mit P 1TRAVDOC Travel Documentation B 1BUSLIC Business Lic:nse B Community Development 10300 Torre Avenue '` Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 OTPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: -�- LAJ Lt 01 PHONE # t-/k.5 ^ Z S 7 GENERAL CONTRACTOR: FAX # 7 - t I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI:vESS 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 er/Contractor Signature Date