12100012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7933 CRANBERRY CIR CO\FRAC'FOR:NUSSEY BROS INC PERMIT NO: 12100012
OWNER'S NAME: NOLAN ROBERT 1 AND SANDRA 1 903 GEORGE ST DATE ISSUED: 10/02/2012
OXYNER'S PIIONF.: 4082533985 SANTA CLARA,CA 95054 PDONE NO:(408)733-6360
❑ LICENSED CONrRACFOR'S DECLARATION .JOB DESCRIPTION: RESIDE'NUTAI.U COMMERCIAI.
License Class CSO Lic.f S REMOVE AND REPLACE FURNACE IN SAME LOCATION
3TON
Contractor Date SPLIT SYSTEM
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5200
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code;for the performance of the work for which this AIIN Number:36203006.00 Occupancy Type:
permit is issued.
%IIPI.ICAN'I'CEIZ'I'IFICAI'ION'
1 certify,that I have read this application and sone that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LA-U CALLED INSPECTION.
indem/kccp css the City ofCupertino against liabilities,judemen6,
costs, i may accrue a ainst said City in consequence of the ratinAdditional t1 applicant understands and will comply Issued by: Date:
with ae regulati p r the Cupertino Municipal Code,Section
9.18.
rj RF:ROOFS:
Signat Date 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 materials for
inspection.
❑ WNFR-BUILDER DECLARA I'ION
Signature of Applicant: Dale.
hereby affirm that 1 am exempt from the Contractor's Liccnsc Umfor one of
the following nvo reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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&Professions Code)
1,as owner of the property,run exclusively contracting with licensed contractors to I IA'/.ARDOUS MATERIALS DISCLOSURE.
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilcalth&Safm Code.Sections 25505.25533.and 25534. 1 will
1 hereby affirm under penalty of perjury one of the follmving three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: Ilcalth&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 us nip at or evices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by erl it Quality Management District I
performance of the work for which this permit is Issued. \\'Ill maintain cnmpinmen\\'I ripe! i Dlunicipal Cade.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the I Iealth&Safety Code ec 'ons 255 5533,and 25534.
Section 3700 of the labor Code,for the performance of the work for which this
Orr Oner or authorize)agent: Date:
permit is issued.
I certify that in the performance of the work for Which this permit is issued,I shall
not employ any person in any manner sou to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CER'TIF'ICATION Lender's Address
I certify that 1 have read this application mid state that the above information is
correct. I agree to comply with all city and county ordinances and state Imus relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep hamdess the City of Cupertino against liabilities,judgments, ARCIIITECI"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date -
- -rtuiiit iisfuu.�'i•Lc.--- _ In vnrur yv
Work Without Permit? Q Yes Q No $0.001 1
GENERAL PERMIT APPLICATION Irl E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 1 '\e/'� p I S I
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildinarCDCUDerino.ora ` O
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❑PLUMBING �ff/.yCHA,N'ICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT 'J�Q ,..�J. ✓O /• /J IAPNp 2LPZ C)3 00
OWNER NAME—yr/fSK/ / PH n —.J -MAIL li`-'
STREETADD .`3.3 ICITY,STA &%t" e n/�:/I a�jT/ FAX
CONTACT NAME PHONE (' E-MAIL
STREETADDRESS CITY.STATE, ZIP FAX
KNER ❑ OKNER-BUHDER ❑ OWNZRAGc T ❑ CON CTOR ❑CONTRACTOR AGFNT ❑ ARCHITECT ❑UJGH+EER ❑ DEVEIAPFA ❑ T ANT
CONTRACTOR NAt � LIC 5 HUS.LIC a
COMPANY NAME y D� I E-MAIL E7 / FAX
STREET ADORES t 3 v CJ ( I CfTY.STA ZIP FH -733- /
ARCIi=/ENGINEER NAME LICENSE YUMSER I BU .UC p CJ 5U^
COMPANY NAME E-MAH. FAX
STREET ADDRESS CITY,STATE,Z[P FHONE
USE OF ❑SFO v DUI`F M[JLT]-FAMILY PROJECT IN W[LDLAND ❑ YES PROJECT N ❑YES IS THE BIDG AN
B=NG: SCO M RCIAC- LRHAN N'Tc7tFACE AREA ANO FLOOD ZONE ❑NO EIRH.FRHOME7 NO
DESCRIPTION OF WORK
�� �c�ov`T' 3Tor/ S.�G� --•tel �tL s
TOTAL VALUATION: U ✓ I RECEIVED BY:
By my signature below,[certify,o etch .'.e 311owin I th ro --y 0'm or au[horfud Igen[to ac[on the property owner's behalf. I have read this
application and the infomation I hav r9 'tied is co a Tea the Dese.prion of Work and verity it is aecvate. I agree w comply with all applicable local
ordinances and sate laws relating' ouildin i zutho -mp¢ ,mtivm of Cuprnino to enter the above-i tifie property for inspection purposes.
Signature of Appliwnt/Ageau Date:
S NTAL IiWFOR. 70NUIRED OFFICE USE ONLY
y ❑ OVER-THE-COUMER
Y
- ❑
EXPRESS
1
J
❑ STANDARD
V
Z ❑ IARCE
5
❑ MAJOR
AEPAfucApp_2011.doc revised 06/21111