09030046 CITE'OF CUPERTINO
BUILDING DWISION PERMIT
r
BUILDING ADDRESS: PERMIT NO.
10940 migmowp Rn TRT) TO BE DFTFRMTNFn 0903004.6
OWNER'S NAME: PERMIT ISSUE DATE
PHO SAAW 12 0 0 9 CONTROL NO.
ARCHITECT/ENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REPLIhCE EXISTING FURNACE D D D D
c31%Zi LICENSED CONTRACTOR'S DECLARATION
u I hereby arm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section affirm
7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and eff, Z O
j r�Z License CI Lie.N
t p Datc 3 / Contractor 447JE CA-4Z"fCkA•�
t7+] ARCHfrECI'S DECLARATION
I understand my plans shall be used as public records
�yU
4 Q w Licensed Professional
n 0OWNER-BUILDER DECLARATION
V2 I
2<z I hereby affirm that 1 am exempt from rhe Contractor's License Law for the
L D o following reason.(Section 70315,Business and Professions Code:Any city or county
4_� which requires a permit to construct,alter,improve,demolish•or repair any structure
Z yy prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions or the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Wan five hundred dollars(5500).
❑I•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
and Professions code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own 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 L-
eone 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.
C]I am exempt under Sec .B&P C for this mason
OwnerDate
WORKER'S COMPENSATION DECLARATION
4I hereby affirm under penalty of perjury one of the following declarations:
I1avee and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance or the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
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 performs of the w rk for which non is issued,I shall not
employ any person in any goner � orkcrs'Compensation
Laws of California.Dat
Applicant 1-1
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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z►r CONSTRUCTION LENDING AGENCY
E-r ate+ I hereby affirm that there is a construction lending agency for the performance of
fli the work for which this permit is issued(Sec.3097,Civ.C.)
WCL A Lenders Name
a z Lenders Address
V 0 1 certify that I have read this application and state that the above information is
LL correct.I 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
U
above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
co) liabilities,judgments,costs and expenses which may in any way accnre against said City
V Z in consequence of the tog of this rmit
"y APPLICANT UN it A WILL COMPLY WITH ALL NO -P INT Issued)y: Date
SOURCE goU ,y
A�5
Re-roo's
stun pplicant/Comractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municip odc.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roo's shall be inspected prior to any roofing material being installed.
C]Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as dcfuncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
1 have read the hazardous materials re iremc is under Chapter 6.95 of the Califor•
nia Health&Saf Co ,Sections 25505. 3 25534.1 understand that if building
does not cu a tenant,that it' my ponsibility to notify the pant of the
requiremc a nu i eraeenifieaeoroc Signature of Applicant Date
owne autharizcdagcnt Dae All roof coverings to be Class" .`'or better
Community Development
10300 Torre Avenue
a Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
CUPEkTINO
Buildi�n De artment
JOB ADDRESS: j PERMIT #
OWNER'S NAME: PHONE # 'le),? 3 4, 8,0 Ra
GENERAL CONTRACTOR: Or FAX # 333 W�
I am not using any subcontractor .
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
Date
Owner/Contractor Signature
CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
�2�1.CA-) /0
Building Address:
1 qO W(0,nvn�—e "ki
Owner's Name: Phone#:
Orr n I , '-/oF 72-5-- /7&7
Contractor: i // Phone#: �o�- .3&1–?,o a b
IVO r- lt4-e Fax#: 400' 333 - `1/ Rp
Contractor License#: Cupertino Business License#:
c2o - � . �87c�
Contact: Phone#: wso Y3-7- & :377
JaM e 5 CRUS / Fax#: yob 3�33
Building Permit Info:
Elect El Plumb El Mech
ResidentialITCommercial El
Job Description:
For Residential Installations:
Attic ❑ 1St floor ]' 2'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 Re uired
Cost of Project: 010— Type of Construction(Usage Class):
10, 2$00
Strapped On PlatformEl Bonded New Location Replacement
Project Size: Express Q Standard ❑ Lar e ❑ Ma or
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 0l/07/09
CITY OF CUPERTINO
FUR�vACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Feg ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-Itepair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,a sorption unit,or ea
heating,coolir g,absorption or
evaporative cajoling system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial f i)r the repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption un.t or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial I nstall/Relocate ea M
suspended he.tter,recessed wall htr, or
floor mountec.unit heater.
1 PGASCOM Commerical f or ea gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlot.
1 MCAPPVNT Commercial for the install/relocate/ or M
replacement c f ea appliance vent
installed& nc t incl in an appliance
rmit.
1BCBSC Cal Bldg Star dards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICO Commercial Seismic B
1MRRAA Residential RI-pair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,coolitLg,absorption or
evaporative cajoling system,incl
installation of'controls regulated by
this code.
l MRSUSHTR Residential Ir stall/Relocate ea M
suspended heater,recessed wall htr, or
floor mounter L unit heater.
CITY OF C'UPERTINO
FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Descriptioa Fee Permit Type
Group
IMRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install¬ incl in an a 1 permit.
FURNACE —W—RN/AC
1PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas p iping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standa-ds Commission Fee B ALL PERMIT
1 TYPES
1 BSEISMICR Residential Seisj nic B
1NiECPLNCK Mechanical Plar.Check M
1 MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
I MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea ford:d-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance over
100,000 Btu/h
I IEPERMITFEE Electric Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
I 1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
I
I1BUSLIC Business Licen>e B