The URL can be used to link to this page

09060079 CITY•OF CUPERTINO BUILDING DIVISION PERMITNL � BUILDING ADDRESS: PERMIT NO. f PERMIT ISSUE DATE OWNER'S NAME: rHONBER )RTHRUP ST SA CONTROL NO. ABUILDING PERMIT INFO RCHiTECT/ENGINEER: BLDG ELECT PLUMB MECH REPLACE FURNACE ADD A/C IN D O O D u O p LICENSED CONTRACTOR'S DECLARATION SIDE YARD Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professions Cotte,and my license is Ln in full force and effect o ZZ Drn Z Licenac as Lie. F p Date Contractor ARCHf1ECTS DECLA O t I understand my plans shill be used as public records D U U.y Licensed Professional y OWNER-BUILDER DECLARATION <� I hereby affirm that 1 am exempt from the Contractor's License Law for the LOO following mason.(Section 703 1.5,Business and Professions Code:Any city or county 42 which requires a permit to construct,liter.improve.demolish,or repair any structure 4Z- prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation 251 that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 Sq.Ft.Floor Area XF$ (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 eumptioa 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($500). ❑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 to in 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.). ❑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 U- 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. ❑1 am exempt under Sec. B dt P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury ane 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 work 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. MyWor s Comp nsation In ranee carrier and Policy number a�re��:33rr carter Policy No.:12221 Z CERTIFICATE OF X PTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc hundred dollars($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 Z forthwith comply with such provisions or this permit shall be deemed revoked. ZCONS"" TRUCTION LENDING AGENCY [i rA I hereby affirm that them is a construction lending agency for the performance of (Y the work for which this permit is issued(Sec.3097.Civ.C.) WGI.A Lendefs Name Z Lcndet's Address V C) I certify that I have read this application and state that the above information is LL cortccL I agree to comply with all city and county ordinances and state laws relating to 0 V building construction.and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against p.j rA liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. Date ►-h APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON- OINT Issued by SOUR U ONS. � D Re-roofs Sign m uorKpplicanvconuack6r/ ate Type Of RoofHAZA S 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. ❑Yes If a roof s installed without first obtaining an inspection,I agree to remove Will the applicant or tum building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑YesNa 1 have read the hazard/aux materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505 25533 and 25534.1 understand that if the building docs not currently have a tenant,that My risibility to notify the occupant of the req cnts which be ct priorf a Ccrt(fhcatc of Oc panty. $lgnaturE Of Applicant Date D te_ All roof coverings to be Class' j"or better O ncr o authonzcd agent Community Development 10300 Torre Avenue A ' . { Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT# &6 OWNER'S NAME: — PHONE # = — 2,46 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: L l ignature 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 CITY OF CUPERTINO FUR1vACE/AC CUPEi�TINO PERMIT APPLICATION FORM APN # ��'✓ 6U Date: Building Address: 1/67 Owner's e: �, PhoS'3 Vl--52�01,:;, Contractor: Phone#: "8 —Z-13-713,f /11 t Wim- Fax#: Contractor License#: Cupertino Business License#: f-7 Contact: Phone#: Fax#: Building Permit Info: Elect Plumb ®- Mech Residential Commercial ❑ Job Description: C, (J'Ug kA&d fcic- a��J For Residential Installations: Attic El 1St floor �4 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): i t S'(GLV P-,3 Strapped El On PlatformEl 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. Revised 01/07/09 CITY OF C UPERTINO ` FURNA.CE/AC CUPEf�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1MCRAA Commercial-Rep;iir/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,al)sorption or evaporative cooli ig system,incl installation of controls regulated by this code. 1 MCREPALT Commercial for tie repair of alt/add to M ea heating appliwice,refrigeration unit,cooling unit,VAV boxes, absorption unit or ea heathing, cooling absorption,or evaporative cooling sys, incl install of controls regulated by this code. 1 MCSUSHTR Commercial Install/Relocate ea M suspended heater,recessed wall htr, or floor mounted un it heater. 1PGASCOM Commerical for ca gas piping System P 1-4 outlets 1BPGAS 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 incl in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,absorption unit,or ea heating,cooling,,bsorption or evaporative cooling system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Install/Relocate ea M suspended heater.-,recessed wall htr, or floor mounted unit heater. CITY OF CUPERTINO FURNACE/AC CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Descriplion Fee Permit Type Group 1 MRAPPVNT Residential fa-the install/relocate/or M replacement of ea appliance vent install &not incl in an ap 1 permit. FURNACE FURN/AC 1 PGASRES Residential fo-ea gas piping system of P 1-4 Outlets 1BPGAS For each gas piping system of 5 or P more per outl(;t. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 1BSEISMICR Residential Seismic B 1 MECPLNCK Mechanical P.an Check M 1MFR=<100 Furnace Syst =100k BTU install or M relocate ea forced-air/gravity type furnace/burner, incl ducts/vents attached to such appliance up to and include 100,0)0 Btu/h 1 MFRN>100 Furnace Syst > l 00k BTU install or M relocate ea fo-ced-air/gravity type furnace/burne r, incl ducts/vents attached to such appliance over 100,000 BtuAi IEPERMITFEE Electric Permit Fee E I 1MPERMITFEE Mechanical Permit Fee M / 1PPERMITFEE Plumbing Peimit P 1TRAVDOC Travel Documentation B 1BUSLIC Business License B