09030038 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ` "
PERMIT NO.
BUILDING ADDRESS:
ELM -Anng
7464 FA PERMIT ISSUE DATE
OWNER'S NAME:
1:06 8 SA �28000NTROL NO.
10
BUILDING PERMITINFO
ARCHITECi7ENGINEER: BLDG ELECT PLUMB MECH
CHANGE OUT FURNACE AND ADDA I
u o a LICENSED CONTRACTOR'S DECLARATION ON A/C SAME LOCATION Job Description
;I m C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
_Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
!',<y in full force and xfectf,,I__)A �.g 21V .0 Q
-Z License Claw �T t- Contnwr
p Date c
tar ARCHri'ECTS DECLARATION
g 9< 1 understand my plans shall he used as public records
D
wo I- Licensed Professional
< OWNER-BUILDER DECLARATION
n.:5
1 hereby alTirm that 1 am exempt from the Contractor's License Law for the
'�p% following reason.(Section 7031.5,Business and Professions Codc:Any city or county
K.646 which requires a permit to construct alter,improve,demolish,or repair any structure
>a'y prior m its issuance,also requires the applicant for such permit to file a signed statement gq Ft.Floor Area Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
IS- (commencing with Section 7000)of Division 3 of the Business and Professions Code)oY. r
y 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(5500)_
❑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 leaden 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 Contracwes
License Law. B&P C for this reason
1 am exempt under Sec
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workces Compcn-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Q 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 Wor is nsati9qiniturancfarrier and Policy numb are / f7
Carrier. CL Policy No.:
CERTIFI TE OF CEMPTTON FROM WO ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z r 4 CONSTRUCTION LENDING AGENCY
I hereby affirm that dare is a construction lending agency for the performance of
IYi.7 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendces Name
0Z
Lender's Address
V 0 1 certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
shove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
►F.t liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
0-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b:i:
SOURCE REGfJLAPONS. 3,
�b
A __
Re-roofsSignature of Applof Applicant/Contractor a
HAZARDOUS MATERIALS DISCLOSURE Type of 'loof
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 roof:-,shall be inspected prior to any roofing material being installed.
C3 Yes ONO 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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safciy Codc,Sections 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 Date
requiremcn w' h must be met prior to issuance of a C ate of capancy. Signature of Applicant
p All roof coverings to be Class"J�''or better
Owner or authorized agent Dare
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
Date:
APN # �Q 02,1. no mozoel
Building Address: / C A
Owner's Name: Phone#: r
o G�
Contractor: V Phone#:(-�-U
(k-0- v, l I)Iv Fax M
Contractor License#: Cupertino Business License M
r S
Contact: Phone#: r,
(A ck 61 Fax M
Building Permit Info:
Elect Plumb ❑ Mech
Residential Commercial ❑
Job Description: /
CJ1 C-,�-of- o (Cy
For Residential Installations:
Attic [—] 1St floor 2nd floor El
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: \P,0 Type of Construction (Usage Class):
Itrz
Strapped On Platform ❑ Bon(led New Location Replacement
Project Size: Express Standard ❑ Large❑ Major❑ P1
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
CUPEf�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Repair/Alteration/Add to M
ea heating appliar.ce,refrigeration unit,
cooling unit,absoiption unit,or ea
heating,cooling,ab sorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for fAe 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 heatei,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for i;a gas piping System P
1-4 outlets
1 BPGAS For each gas pip:ng system of 5 or P
more per outlet.
1MCAPPVNT Commercial for -.he install/relocate/ or M
replacement of ea appliance vent
installed & not incl in an appliance
,permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Sei3mlc B
1MRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,abs:)rption unit,or ea —
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Instill/Relocate ea M
suspended heatex,recessed wall htr, or
floor mounted L.nit heater.
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Units <= lOk CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standams Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for e gas piping System P
1-4 outlets
1PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piling system of 5 or P
more per outlet. Comm/Resid
1 BREMAIRHAN Residential A/C units<= l Ok CFM B
1MRRAA Residential Mecb Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
J TYPES
/ 1BSEISMICR Seismic Residenlial B
1 EPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Pernlit M
1 PPERMITFEE Plumbing Permi-: P
l
IT AVDOC Travel Documentation B
1BUSLIC Business License B