09060124 CITY OF CUPERTINO
BUILDING DIVISION PERMITFP
O: IFtATI�lY�
BUILDING ADDRESS: PERMIT NO.
RFMR ATR SYSTEMS
OWNER'S NAME: PERMIT ISSUE DATE
�OA CONTROL NO,
(408) 375-0406
ARCH]TECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 70(10)of Division 3 of the Business and f ons ode,and my license is
z y in full force and effect Z FURNC C G OUT & A/C ADD—ON — BSL RENEWD.
vn Z License Mass --Lic.8
n E,o Dae L17 SI Contractor Q�
ARCH IIECI'SDECLARATION
1 understand my plans shall be used as public records
d
G
in Licensed Professional
n y 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
0 O following mason.(Section 7031.5,Business and Professions Code:Any city or county
1:0
m 9 which requires a permit to construct.slier,improve•dcmolLsh,or repair any structure
u z} prior to its issuance,also requires the applicant for such permit to file a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y.
t•- (commencing with Section 7000)of Division 3 of Oe Businessand Professions Code)or 1 2 7 7 2
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(5500)
❑I•as owner of the property.or my employees with wages as their sole compensation, 35626009 . 0 0
will do the work,and time structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conhe nsactoes 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 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 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.
❑1 am exempt under Sec B tit P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
..ation,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.
My Work(eer'ssCCom�jns�aGonoln�sa�tance carrier and Policy number are: y
Cartier Policy No.:W C S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Rothe completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.1 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 5, CONSTRUCTION LENDING AGENCY
[~i rA 1 hereby affirm that there is a construction lending agency for the performance of
p;nthe work for which this permit is issued(Sec.3097•Civ.C.)
aQ Lender's Name
2 Lender's Address
U C) 1 certify that I have read this application and state that the above information is
LL►-" correct.1 agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned proper inspecdon purposes
(We)agree to in mnify and keep harmless the City of Cupertino against
►F-u!n liabilities,judgments, osis an expenses which may in anyway accrue against said City /
U z in conseq a the in
f this permit.
APPLIC STAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR �
Z Z c Re-roofs
Signal pplicant/Contractor Date '
HAZARDOUS MATERIALS DISCLOSURE Type of Loof
Will the applicant or future building occupant atom 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 9T9.-
If a roof:s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
nil hazardous air contaminants as defined by the Bay Area Air Quality Manasemcnt all new materials for inspection.
iistrict?
❑Yes VrNo
I have mad the ous materials requirements under Chapter 6.95 of the Califor-
nia Health ty C So dons 25505,25533 and 25534.1 undcrstarrd drat if the building
docs n c n y vc a ant.that it my,rc.p..ihility to notify the occupant of the
rcqui issuance of a Certircatc of occupancy. Signature Of Applicant Date
On r authorised agent Date
2ZAll roof coverings to be Class'n"'or better
CITY OF CUPERTINO
{ FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN# Ac, V9 + c-) 0 101. 1
Date:
Building Address:
Contractor: U
Ptmp ne#:
S lS C P cr-0, r, \� �v� S I V",'s Fax#:
Contractor License#: Cupertino Business License#:
4 (� cel l _
Contact: Phone#: ��g 3� ( 04 ,
S Ac 6k m e Fax#:
Building Permit Info:
Elect Plumb Mech
Reside tial] Commercial E]
Job Description:
�-u ( y\-c,,ccj Adc
For Residential Installations:
Attic ❑ 1st floor �� 2na 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):
Strapped ❑ On Platform ❑ Bondcd Q— New Location° Replacement❑�
Project Size: Express Q-- 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