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CITY OF CUPEK11
BUILDING DIVISION
BUILDING ADDRESS:
OWNER'S NAME:
ARCHr1ECf/ENGINEER:
PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions C and my license is
in ful5fowe MandKto .9��
I
pare Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve. demolish, or repair any structure
prior to its issuance, 1190 requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the previsions of the Contractoeur's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Businand Profession$ Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Secon ti70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
0 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 Contractor's 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 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 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.
0 I am exempt under See . B lk P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury cote of the following declarations:
r have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
aation, 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
of the Labor Code, for the performance of the work for which this permit is issued.
My Wo Ir
Carrie . s Compensation Insurance carrier and Policy num 1 r
rU Po
No.;,,r�
CERTIFICATE OF XEMP77ON FROM WORKERS'
COMPENSATION INSURANCE
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(This section need not be completed if the permit is for one hundred dollars ($100)
or less)
[ 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 Workcrs' Compensation
Laws of California Dale
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
forthwith comply with such provisions or this permit shall be deemed revoked.
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.)
Lender's Name
Lender's Address
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
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S RCE EG CATIONS. tkAl O A
Signature of Applicant/Contractor Dare
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)? \ /
0 Yes o
Will the applicant or future building occupant use equipment or devices which
.t hazardous air contaminants as defined by the Bay Area Air Quality Management
,strict?
0 Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia
alifonnia Health do Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is risibility to notify the occupant of the
"ffqm cn yrhiclr 14 ,14 psi r�/Nf a C ' tcatc ofOc t;1-) I it &I
Owner or authorized
978—
FURNACE CHANGE OUT
. Ft. Floor Area
37526001.00
Issued b3
Re -roofs
Type of Roof
Job Description
Occupancy 'Type
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new rlaterials for inspection.
Signaturt; of Applicant
All roof coverings to be Class ':FF' or better
Date
PERMIT NO.
PERMIT ISSUE DATE
S A
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECTPLUMB
MECH
0
(� 0
Job Description
Occupancy 'Type
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new rlaterials for inspection.
Signaturt; of Applicant
All roof coverings to be Class ':FF' or better
Date
CITY OF CUPERTINO
FURNACE/AC
CUPEItTiNO PERMIT APPLICATION FORM
APN #- �A (Po ff' �C
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Date:
Building Address: bon e5t Gf ^ ' `i t UA
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Owner's Name: /�1,,
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Phone #:
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Contractor:
Phone #: 4cK q--1 Id --k0cc5o
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Fax #: LLCJ? T1 Q `=11 TO
Contractor License #:
Cupertino Business License #:
<�Oa <908
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Contact:
Phone #: t�J -Q-) t , -1-CXoc3
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Fax #: L4 -,C t
Building Permit Info:
Elect Plumb E] Mech tK
Residential Commercial ❑
Job Description:
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For Residential Installations:
Attic ❑ 1St floor � 2"d floor E:1
Adhere to minimum setback requirement
For Commercial Installations:
[:1Structural
Replacement same weight ❑ Additional weight (structural Gales)
Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
�Lpq) . -- 1
Strapped ❑ On Platform ❑ Bonded ❑ 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, include in plan set & the sheet index.
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