09040147 CITY OF CUPERTINO yt p
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
21350 RAINBOW DR CONDIT -ONET)
OWNER'S NAME: PERMIT ISSUE DATE
HO : S A CONTROL NO,
408) 2111-2220
ARCHrf'ECT/ENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7 )of Division 3 of the Business and Professions and my license is
y in me force an f 1 RMV & RPLC FURNC & A/C.
j n Z Licep Cl Lte•N
F- Dam" CHi7 ECTS DECLA ON Rif
< I understand my plans shall be used as public records 1r
�yU
u.In Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
COO following mason.(Section 7031.5,Business and Professions Code:Any city or county
K ru which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 5
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(SM. 36651008 . 00
0 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 Conuactoes License Law does not apply m ns an owner of q P
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.).
0 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-
ccnse Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor($)licensed pursuant to the Contractors
License Law.
0 1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Consent to self-insure for worker's Compcn-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cade,for the performance of the work for which this permit is issued.
My Worker's Com�p"gQsatiop�6hgutapCe c3aicr and Policy.tmgcr q
Cartier. C Y(i,K � Policy No.-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fox 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
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.)
aA Lendces Name
a Lender's Address
U 0 I certify that I have read this application and state that the above information is
correct.I agree m comply with all city and county ordinances and state laws relating m
0 V building construction,and hereby authorize rcpresentatvcs of this city to enter upon the
a above-mentioned property for inspection purposes
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U ZrPPLI
uence of the gran' omit. L �G
r"h DERST S AN C1j� OMPLY WITH ALL NON-POINT Issued b": Date 0 RE \
Re-roofs
Signature fApplicant/Contracmr Date Type of]roof
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
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes 20--
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.
District?
0 Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Scclions 25534.1 understand that if the building
does not currently have a tenan at it is my responsi i the occupant of the
requiremc nich t prior m issuance oCa Ccnifcate of a .�___ Signature:of Applicant Date
m Dam All roof coverings to be Class'A�'or better
Owner or authorized agc
CITY uq
O F C UPERTINO
=' FURNACE/AC
c"
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
2. t 35 ��c� ,� Lk) Co rA.-,r1G C, S I c1
Owner's Name: Phone#:
C v;,n C. h 0 Z55 • Z.13 9
Contractor: Phone#: l
c ,
ane
c, Fax#:
Contractor License#: Cupertino Business License#:
Contact: Phone#:
fico �� � '�. �3`�rrrC
Fax #:
Building Permit Info:
Elect D -
Plumb ❑ Mech
Job Description: ��W
(.[p re Cv ("Ye i� C
Residential Commercial
For Residential Installations:
Attic 1st floor ❑ 2nd 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 Ccnstruc n (Usage Class):
1 1 , oho • Q
Strapped D On Platform Bonded New Location S'— Replacement
Valuation:
Green Building: Must attach Green Building Check list to this application
CITY OF CUPERTINO
M FURNACE/AC
CITY-UPEI�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 applimce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,;ibsorption or
evaporative cooling system,incl
installation of ccntrols regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appliEnce,refrigeration
unit,cooling unit,VAV boxes,
absorption unit cr ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heater.-,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for -a gas piping System P
1-4 outlets
1 BPGAS For each gas pip.ng system of 5 or P
more per outlet.
1 MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ incl in an appliance
permit.
1BCBSC Cal Bldg Standa:-ds Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential RepE.ir/Alteration/Add to M
ea heating appliznce,refrigeration unit,
J cooling unit,absorption unit,or ea
/ heating,cooling,,ibsorption or
evaporative cooling system,incl
installation of ccntrols regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heatei-,recessed wall htr, or
floor mounted unlit heater.
CITY OF CUPERTINO
FURNACE/AC
CITYCUPEf�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Units<= 1 O CFM B
1 MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICO 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 piI ing system of 5 or P
more per outlet. C'omm/Resid
1BREMAIRHAN Residential A/C L.nits <= 10k CFM B
1 MRRAA Residential Mecb Repair/alt/add M
1BCBSC Cal Bldg Standar is Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1 1TRAVDOC Travel Documentation B
1BUSLIC Business License B
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
rM OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT#
OWNER'S NAME: ? c PHONE #
GENERAL CONTRAC rOl : ('� ���c �\ FAX# C -, � c
I am not using any subcontractors: `
Sim a
Date
Please check applicable subcontractor. -a ccm lete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &iE7w, 4k
Cement Finishing
Electrical
Excavation
Fencing
Flooring:Carpet n"
i
Linoleum/ Wood ,;
Glass/ Glazing! ` Zi
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpapjer
Paving
Plastering
Plumbing
Roofing
Septic
Sh t Metal
Sheet Rock
Tile
Owner/ ntra pr Signature ate
r7-