09040074 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
11 PERMIT NO.
BUILDING ADDRESS:
1051 PENNINGTON LN ATLAS-Tf:ILLO HVAC 09040074
PERMIT ISSUE DATE
OWNER'S NAME:
RTTTT T+R T>ATTT V AMT) Tn(7n1JELIN S A CONTROL NO.
)NSF:
(408) 286-8931
BUILDING PERMIT INFO
ARCHITEL-r/ENGINEER: BLDG ELECT PLUMB MECH
a 0 0 0
v p p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Zrnwith Section 7060)of Division 3 of the Business and Prof, � odc,
in full force and elft. and license is FU}�Nc & A/C
aIM # 6'
Licenac
n F,O Date_ / Contractor
ARCHITECTS DECLARA71
I understand my plans shall be used az public records
D,U
`O y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K Pi which requires a permit to construct alter,improve,demolish,or repair any structure
Ll prior to its issuance,also requires the applicant for such permit to file a signed statementValuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor Area
yI=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5800
y 5 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). 36204033 . 00
❑I,as owner of the property,or my employees with wages az 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 Contractors 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 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 Contractors
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 Workers Compen-
sation,az 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,az required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wor=CERTIFICATE
ncur/ice artier and Policynu r
Cartier. L Policy No
`l
OF EX PTION FROM WORKS
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,1 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 Workers Compensation provisions of the Labor Code,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z�4 CONSTRUCTION LENDING AGENCY
F~t■A 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.) ,
W Q Lenders Name
z Lcndees Address
V O 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
0 V building construction,and hereby authorim representatives of this city to enter upon the
W above-mentioned property for inspection Purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the gran' rmit. Date r - j L r U�
APPLICANT UNDER LL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGUL S /^/
% ` G —
Re-zoo s
Sig ofA scan ntractor Date r�
Type of 1~:oof
HAZARDOUS MATERIALS DISCLOSURE
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
Cotte,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
A hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety C ons 25505,25533 and 25534.1 undcmmd that if the building
does not current t i ' y responsibility to notify the occupant of the
mquiremc It �C Signature of Applicant Date
�� All roof coverings to be Class"{"or better
O ncr r authorized agent Datc
0 oL4 0 (-Y-1 �
CITY OF CUPERTINO
FURNACE/AC
CUPEf�TINO PERMIT APPLICATION FORM
APN # Date:
� Q 0 I
Building Address:
105 Lainp
Owner's Name:
Phone#:
I^er L4 08 2:92
Contractor: Phone#: I ag ag a R 5 a 7
A+tm 'Tri, h Fax#: 409 7 S >!
Contractor License#: Cupertino Business License#:
Contact: Phone#: 40% 246Z,q50�-
-- XM ('cc Jvvia(s Fax #:
Building Permit Info:
Elect Plumb Mech
_z_
Residential Commercial ❑
Job Description:
rw,p- ovLd
For Residential Installations:
Attic El 1St floor [r, 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 H On Platform ❑ Bonc ed New Location❑ Replacement
Project Size: Express ❑ Standard [ Large ] Major❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, inc Mde in plan set & the sheet index.
Revised 01/07/09
CITY OF C UPERTINO
FURNA.CE/AC
CUPEf�T1NO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-Rep�iir/Alteration/Add to M
ea heating applialLce,refrigeration unit,
cooling unit,absoiption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
I MCREPALT Commercial for fie repair of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit of ea heathing, cooling
absorption,or evajorative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR Commercial Inst,.11/Relocate ea M
suspended heater recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for ca gas piping System P
1-4 outlets
1 BPGAS For each gas pipi:ig system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of e<< appliance vent
installed & not incl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
r TYPES
1BSEISMICO Commercial Seismic B
1MRRAA Residential Repair/Alteration/Add to M
ea heating appliaace,refrigeration unit,
cooling unit,abscrption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of co itrols regulated by
this code.
1MRSUSHTR Residential Instal/Relocate ea M
suspended heatei,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
FUIVIACE/AC
OF
CUPEkTINO FEE S(--.'HEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
1 MRAPPVNT Residential for the install/relocate/or M
replacement of ea appliance vent
install ¬ in cl in an appl permit.
FURNACE FURN/AC
1PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS 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 Se_smic B
1 MECPLNCK Mechanical P1 in Check M
1MFR=<100 Furnace Syst =100k BTU install or M
relocate ea for-,ed-air/gravity type
furnace/burner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst l 00k BTU install or M
relocate ea forced-air/gravity type
furnace/burna-, incl ducts/vents
attached to such appliance over
100,000 Btu/b
IEPERMITFEE Electric Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Per.nit P
1 —
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
CITY OF CUPERTINO
FURNACEAC
OF
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1 BCAIRHAN Commercial A/C Units <= 1 Ok CFM B
1 MCRAA Commercial Mecr Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Seismic Commercial B
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1BREMAIRHAN Residential A/C units<= IOk CFM B
/ 1 MRRAA Residential Mech Repair/alt/add M
I
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
IEPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1TRAVDOC Travel Documentation B
1BUSLIC Business License B
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
C1Tlf OF Fax(408)777-3333
XPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE #-'*/(? � b `-
GENERAL CONTRACTOR: I-tz -/c FAX # (� --r�- � l
I am not using any subcontractors:
Si,mature 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
Owner/Contractor Signature Date