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09060006 77777777777 CITY.OF CUPERTINO ��r BUILDING DIVISION PERMIT l�� R �R �tRMTXfI * »: BUILDING ADDRESS: PERMIT NO. 21641 COLUMBUS AIM Tgn — Tn RF nRTRRMTNWp 09060006 OWNER'S NAME: PERMIT LSSUE DATE °'ON : SAN CONTROL NO. ARCHI7ECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH RPLC JPSTAIRS&DWNSTAIR Z p C LICENSED CONTRACTOR'S DECLARATION FURNACE 92%, ADD A/CJolb Description v C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing a=m with Section 7000)of Division 3 of ibe Business and Professions Code,and my license is y in full fora and effect 1-6 z License ass ZC Lic.N .T t- DanC' Contractor ARCHITECTS DEC CTS _ ee I understand my plans shall be used as public records oy Licensed Professional y� OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the a o following reason.(Section 7031.5,Business and Professions Code:Any city or county $ff which requires a permit to construct.alter,improve,demolish,or repair any structure _ 0 prior to its issuance.also requires the applicant for such permit to rile a signed statement Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation YH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 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 rive hundred dollars($500). ❑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 Required Inspections and Professions Code:The Contractor's License Law does not apply to 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 leaden of proving that he did not build or improve for purpose of sale.). ❑1,u 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. ❑I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby strum under penalty of perjury one of the following declarations: t have and will maintain a Certirrtate of Consent to self-insure for Worker's Compen- .on,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ro 1 have and will maintain Workers 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 1 ation insurance carrier and Policy number m: Carrier:.9 sN�tCe�%J V\O Policy No.:`� 1o, b CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars 1$100) or less.) 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 revoked. Z " CONSTRUCTION LENDING AGENCY [~—n t�-r I hereby affirm that there is a construction lending agency for the performance of (Yw✓ the work for which this permit is issued(Sec.3097,Civ.C.) WGI,A Lentos Name 0 z Lenders Address U 0 1 certify that I have read this application and state that the above information is [L" correcL 1 agree to comply with all city and county ordinances and stale laws relating to Obuilding construction,and hereby authorize representatives of this city to enter upon theU above-mentioned property for inspection purposes 0. (We)agree to save,indemnify and keep harmless the City of Cupertino against HIn liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequenc f the granting or anis permit Date �-r APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued b`r: SOURCE R U ONS. (,- 6 1 Re-roofs Signaturef ApplicanVCon Dare T of Roof HAZARDO ATERIALS DISCLOSURE Type Will am applicant or future building occupant store or handle hazardous material as damned by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety Cole,Section 25532(a)? �,�` All roof: shall be inspected prior to any roofing material being installed. K ❑Yes YUIO '��✓ 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 it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. trict? ❑Yes IN. I have mad the hazardous materials mquircmcnts under Chapter 6.95 of the Califor- nia Health&Safe Cadc,Sections 25533 and 25534.1 understand that if the building does not curve y ha a tenant. t my responsibility to notify the occupant of the requircmen hich mat be t iss aCertificatcor pa y. G, Signature.of Applicant Date VLA Owner ortze agcnl Dam All roof coverings to be Class'J4''or better CITY OF CUPERTINO o�' cc'c� i FURNACE/AC CUPEkTINO PERMIT APPLICATION FORM APN # Date: 6- 1 — Building Address: Ca)U nn lo u5 Ave- Owner's Name: Phone#: y"Z% - of Contractor: Phone#: -U -7 UO �G1,i�j�� ti✓� (U �i Fax#: Contractor License#: Cupertino Business License#: I�S`'I ()(0 q 9 Contact: Phone#: y 2 5 --75 0 )E -QUk �� Z Fax #: Building Permit Info: Elect 9) Plumb ❑9 Mech Residential ( Commercial ❑ Job Description: For Residential Installations: Attic 1St floor [] 2°d floor Adhere to minimum setback requirement ❑ For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installatio:i ❑ New installation Planning Approval Required ❑ Cost of Project: Type of(;onstruction (Usage Class): Strapped On Platform Bonded New Location Replacement Project Size: Express ['Standard ❑ Large ❑ Major ❑ Valuation: j// Q 00 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. Revised 01/07/09 CITY OF C'UPERTINO FURNACEAC CUPEI�TINO FEE SC. IEDULE Quantity Fee ID Fee Descriptio:i Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-Rey air/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absc rption unit,or ea heating,cooling,E.bsorption or evaporative cool.ng system,incl installation of controls regulated by this code. 1 MCREPALT Commercial for :he repair of alt/add to M ea heating appliance,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 heata-,recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for -a 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 &not i:icl in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1MRRAA Residential Rep.Lir/Alteration/Add to M ea heating appli-,mce,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,absorption or evaporative coo;ing system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Instilll/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. CITY OF CUPERTINO FURNACE/AC CITYCUPE(�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group AIR FURN/AC CONDITIONING 1 BCAIRHAN Commercial A/C Units <= l 0k CFM B 1MCRAA Commercial Mech Repair/alt/add M 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Seismic Commercial B 1PGASCOM Commerical for ca gas piping System P 1-4 outlets 1PGASRES Residential for e�L gas piping system P of 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outlet. Comm/Resid 1 BREMAIRHAN Residential A/C units<= l 0k CFM B 1 MRRAA Residential Mech Repair/alt/add M 1BCBSC Cal Bldg Standaids Commission Fee B ALL PERMIT TYPES f 1 BSEISMICR Seismic Residen-:ial B 1 EPERMITFEE Electric Permit E 1MPERMITFEE Mechanical Permit M 1PPERMITFEE Plumbing Permit P I 1TRAVDOC Travel Documentation B ` 1BUSLIC Business License B 13 Pc.,� �- Community Development 10300 Torre Avenue ,tat, Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 %KkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: pec " S t n PHONE # y0 9- z1 Z/-y yO GENERAL CONTRACTOR:C,,G<c: I am not using any subcontractors: Ali,� __ ----F;igft . e 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 ,X,Ztv,V �-A 90�1� �e / ontrac Signature Date