09050070 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �7= 7777777777
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PERMIT NO.
BUILDING ADDRESS:
7546 HOLLANDERRY PL CONDITIONED AI PERMIT ISSUE DATE
OWNER'S NAME:
r S A CONTROL NO.
PHONE:
(408) 29'--2220
BUILDING PERMIT INFO
'HITECT/ENGINEER: BLDG ELECT PLUMB 0
a p CF
LICENSED CONTRACTOR'S DECLARATION Job Description
tri)= affirm that I am licensed under provisions of Chapter 9(commencing
Z 0)of Division 3 of the Business and Professions Code,and my license is RMV&RPLI, FURNACE & ADD A/C
e H effeS4� 7�
v�ZCG Contractor
3 spy
RCHITECI S DECLARATION
I understand my plans shall be used as public records
�yU
y
4L,
y Licensed Professional
3 OWNER-BUILDER DECLARATION
2I hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section 7031.5.Business and Professions Code:Any city or county
e- which requires a permit to construct.alto,improve,demolish,or repair any structure
„"y prior to its issuance.also requires the applicant for such permit to file a signed statement .Ft.Floor Area Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ��]
Y (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $870 0
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). 36229012 . 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 Contractors License Law does not apply to an owner of
property who builds or improves theroon,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-
cense Law docs 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.
0 1 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 Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
irk 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 Insurance carrier and Policy number am:
Carrier: Policy No.:
R F A I EXEMPTION FRO O ERS' /
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars 1$100)
or Ices)
1 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
Z, forthwith comply with such provisions or this permit shall be deemed revoked.
Z R CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
a, the work for which this permit is issued(Sec.3097.Civ.C.)
W QLender's Name
]z L.cndees Address
V( I certify that I 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 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
PA (we)agree to save,indemnify and keep harmless the City of Cupertino against
,E"y t%I liabilities,judgments,costs and expenses which may in any way scene against said City (�
U Z in consequence of the granting of this permit. Date
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
S==
.
�� Re-roofs
ignature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type Roof
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.
fi
0Yes elaule 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 r.laterials for inspection.
District?
0 Yes >'Nu
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 ifft building
docs no�cur-rendi)o�beor
itis my res bility to til'y the dxcupant of the Date
requirec uso Cc ' ate fOccupany. Signature.of Applicant
All roof coverings to be Class'"or better
Owner or authorized agent Darc
� -U(D
CITY OF CUPERTINO
FURJVACE/AC
CUPEkTiNO PERMIT APPLICATION FORM
APN# Z Date:
Cb It, 19
Building Address:
Owner's Name: Phone#:
C aux 5 e s q,', L,cc 3)
Contractor: Phone#:
11C`i�\CNyj 6 o r t S c-) C Fax #: Z-9 I 2-ZZ9
Contractor License#: Cupertino Business License#:
Flu 51 C2
Contact: Phone#:
Fax #:
Building Permit Info:
Elect Eg-,
Plumb Mech
Job Description: � /J
Residential Commercial 11
For Residential Installations:
Attic ❑ I" floor El 2nd floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight [3-"'
Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
9,10 C) . pU V-6
Strapped On Platform Bonded New LocationEl Replacement
Valuation:
Green Building: Must attach Green Building Check list to this application
CITY OF CUPERTINO
FURNACE/AC
CU P TY OF O FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Rept it/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,atisorption or
evaporative cooling system,incl
installation of controls 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 or ea heathing, cooling
absorption,or eva)orative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR Commercial InstE.11/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1 PGASCOM Commerical for ca gas piping System P
1-4 outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ ir.cl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Sei'mic B
1 MRRAA Residential Rept it/Alteration/Add to M
ea heating applience,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,,tbsorption or
evaporative cooling system,incl
installation of cc ntrols regulated by
this code.
1MRSUSHTR Residential Instz.11/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted u lit heater.
CITY OF CUPERTINO
s ' ` FURNACE/AC
CITYCUPEI�TINO 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
1MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standar is Commission Fee B ALL PERMIT
TYPES
IBSEISMICO Seismic Commerzial B
1PGASCOM Commerical for ca gas piping System P
1-4 outlets
1 PGASRES Residential for ez.gas piping system P
of 1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1 BREMAIRHAN Residential A/C units <= l Ok CFM B
1 MRRAA Residential Mect Repair/alt/add M
i 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICR Seismic Residential B
1
I 1 EPERMITFEE Electric Permit E
f 1MPERMITFEE Mechanical Pern'Lit M
( 1PPERMITFEE Plumbing Permit P
ITRAVDOC Travel Documentation B
IBUSLIC Business License: B
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
CUPEkTINO
Buildi:n De artment
JOB ADDRESLS: PERMIT # 09 _ 07(-j
OWNER'S NAME: PHONE # p c2 OF/
GENERAL CONTR) CTOR: on. �T o FAX # o
I am not using any subcontractors:
Si;;nature 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 o-
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Date
Owner/Contractor Signature