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09030058 CITY DIVISIONITY OF CUPERTINO PERMIT +C� TIACT It ` fk . BUILDING ADDRESS: PERMIT NO. 22168 MCCLELLAN RD ATLAS-TRILLO HVAC n90,10058 OWNER'S NAME: PERMIT ISSUE DATE 1965 KYT.E PARK eT°HONE: SA CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO FURNC & A/C REPLCMNT BLDG ELECT PLUMB MECH q o p LICENSED CONTRACTOR'S DECLARATION O ur 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description with Se Z ction 7000)of Division 3 of the Business and Professions Code. y Ilcense is y in full force and effect. / Z License Lie.x / G -G Date Contractor (i AR HITECTS DECLARATION I understand my plans shall be used as public records a O y Licensed Professional n y OWNER-BUILDER DECLARATION t 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 R$6! which requires a permit to construct,alter,improve,demolish,or repair any structure y Z In prior to its issuance,also requires the applicant for such permit to file a signed statement Z=G that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 Sq.Ft.Floor Area Valuation X F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i r3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy not more than five hundred dollars($500). P Y Type [11,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 Contractor's 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 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.). ❑I,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. ❑I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSA71ON 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 Workers Compcn- ,on,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑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 Worker's Compensation nsursnce ca and Policynum Cirri P Golicy No.: -CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or Icss.) 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 ,J O forthwith comply with such provisions or this permit shall be deemed invoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of �i the work for which this permit is issued(Sec.3097,Civ.C.) WCI. Q Lendces Name ] z Lender's Address U C) I certify that I have read this application and state that the above information is V." carted.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 a above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against Nl/1 liabilides,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. �+ APPLICANT UNDERST/�N WI L COMPLY WITH ALL NON-POINT IS ed b is Date SOURCEREGUL �^ / cit`e-roofs Signat UContractor Dam — HAZARDOUS MATERIALS DISCLOSURE Type of'Zoof 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)? mel All roof: shall be inspected prior to any roofing material being installed. ❑Yes 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 tit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. ,trict? / ❑Yea O 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building ^ �� O does not currently have a tenant,that its my responsibility to notify the occupant of the requirements w ie a f a Ccrtifica N nature of Applicant Date ! I P r of authorized agent Dam L7 All roof coverings to be Class'n"or better 093 �o� CITY OF CUPERTINO FURNACE/AC CUPS a`.-C-10F PERMIT APPLICATION FORM APN # Date: Building Address: 2'L L6 :K Phone#: Owner's Name: C. Cz - 3 6 Contractor: Phone#: 7– � Fax#: 7 3 f Contractor License#: Cupertino Business License#: Contact: Phone#: '�SJ i5 `T 12 - —ll Fax #: Building Permit Info: Elect❑ Plumb ❑ Mech Residential Commercial ❑ Job Description: For Residential Installations: 2nd floor 1:1Attic ❑ 1St floor �� Adhere to minimum setback requirement For Commercial Installations: ❑ Additional weight(structural calcs) ❑ Replacement same weight Structural Calculations required for new installatio i ❑ New installation Planning Approval Required ❑ Cost of Project: G Type of I�onstruction (Usage Class): � oC) Strapped On Platform Bonded New Location Replacement ❑ Project Size: Ex ress ❑ Standard ❑ Lar e ❑ Major❑ – Valuation: Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, in dude in plan set & the sheet index. Revised 01/07/09 CITY OF CUPERTINO FURrfACE/AC CITY OF CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-Re-pair/Alteration/Add to M ea heating appli ance,refrigeration unit, cooling unit,ab;orption unit,or ea heating,cooling,absorption or evaporative coc ling system,incl installation of e Dntrols regulated by this code. 1 MCREPALT Commercial for the repair of alt/add to M ea heating appliance,refrigeration unit,cooling unit,VAV boxes, absorption unit )r ea heathing, cooling absorption,or e,aporative cooling sys, incl install of ccntrols regulated by this code. 1MCSUSHTR Commercial Install/Relocate ea M suspended heatcr,recessed wall htr, or floor mounted unit heater. 1 PGASCOM Commerical for ea gas piping System P 1-4 outlets 1 BPGAS For each gas pif ing system of 5 or P more per outlet. 1.MCAPPVNT Commercial for the install/relocate/ or M replacement of ca appliance vent installed & not i acl in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Sei,mic B 1MRRAA Residential Rep,dr/Alteration/Add to M ea heating appliznce,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 Install/Relocate ea M suspended heater-,recessed wall htr, or floor mounted urdt heater. CITY OF CUPERTINO 1 -9 FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units <= l Ok CFM B IMCRAA Commercial Me(h Repair/alt/add M IBCBSC Cal Bldg Standaids Commission Fee B ALL PERMIT TYPES 1 BSEISMICO Seismic Commei cial B 1 PGASCOM Commerical for ea gas piping System P 1-4 outlets 1PGASRES Residential for epi gas piping system P of 1-4 Outlets 1BPGAS For each gas pi;)ing system of 5 or P more per outlet. Comm/Resid IBREMAIRHAN Residential A/C ,inits <= IOk CFM B I MRRAA Residential Mech Repair/alt/add M r IBCBSC Cal Bldg Standaids Commission Fee B ALL PERMIT TYPES I BSEISMICR Seismic Resident ial B r 1 EPERMITFEE Electric Permit E 1MPERMITFEE Mechanical Permit M 1 PPERMITFEE Plumbing Permit P / 1TRAVDOC Travel Documentation B IBUSLIC Business Licensf B Community Development �3a 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ';UPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: (w c-- PHONE # YO y, GENERAL CONTRACTOR: l /2-�- 2-(0 FAX # 7jc , I am not using any subcontractors: - ignature 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 0 er/Contractor Signature Date