09120012CITY OF CUPERTIN D BUILDING PERMIT
BUILDING ADDRESS: 19250 TILSON AVE
OWNER'S NAME: WINDERMAN STAN/EVA SPERTELL
:R'S PHONE: 4082538086
LICENSED CONTRACTOR'S DECLARATION
License Class 2 Lic. # -_13� '7
ContractorPDate
1 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.
I hereby affirm under penalty 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.
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
permit is issued.
APPLICANT CERTIFICATION
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 authorize 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 accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source relations per the Cupertino Municipal Code, Section
9.18.
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the stricture is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
constrict the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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 so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
1 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 authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
i• iify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CONTRACTOR: COOPER BROTHERS, INC. PERMIT NO: 09120012
.:151 DEL FRANCO ST DATE ISSUED: 12/01/2009
SAN JOSE, CA 95131 PHONE NO: (408) 437-2442
]WILDING PERMIT INFO: BLDG f— ELECT f— PLUMB
MECH f— RESIDENTIAL f— COMMERCIAL
JOB DESCRIPTION: REPLACE FURNACE ADD A/C
•iq. Ft Floor Area: Valuation: $11800
kPN Number: 37540056.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
411 roofs shall be inspected prior to any roofing material being installed. If a roof is
.nstalled without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance w,jth the Cupertino Municipal Code, Chapter 9.12 and the
Health &SafetyCSections 25505, 25533, and 25534.
'
ed agent -
Date:
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constriction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FUR21ACE/AC
CUPEI�TINO PERMIT APPJLICATION FORM
APN # _
0U
Date:
— 1 —C) e7
Building Address:
/s0, -. :, e- C
215
Owner's Name:
Phone #:
Contractor:
Phone #: �t&v 4�,/f ZGC%$
Fax #:
Contractor License #:
Cupertino Business License #:
1�5
.2 6 _73
Contact:
Phone #:
Fax #: WT q3-7- 7 tri
Building Permit Info:
Elect ❑ Plumb ❑
Mech 01-�
Residential V
Commercial ❑
Job Description:
For Resi ential Installations:
Attic ❑ Isc floor [
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):
C 20
Strapped 0 On Platform LJBond ,-d
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, incl ide in plan set & the sheet index.
xevised u1/0//vy
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FUIMACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
1 MRAPPVNT
Residential for the install/relocate/ or
replacement of ea appliance vent
install & not ir cl in an appl permit.
M
FURNACE
FURN/AC
1 PGASRES
Residential for ea gas piping system of
1-4 Outlets
P
1 BPGAS
For each gas piping system of 5 or
more per outlet.
P
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Residential Se- smic
B
1 MECPLNCK
Mechanical Plan Check
M
1MFR=<100
Furnace Syst <=100k BTU install or
relocate ea for,ed-air/gravity type
furnace/burnei, incl ducts/vents
attached to such appliance up to and
include l 00,OC 0 Btu/h
M
1MFRN>100
Furnace Syst =- 100k BTU install or
relocate ea forted-air/gravity type
furnace/burnei, incl ducts/vents
attached to such appliance over
100,000 Btu/h
M
1 EPERMITFEE
Electric Perini t Fee
E
1 MPERMITFEE
Mechanical Pc rmit Fee
M
1PPERMITFEE
Plumbing Permit
P
1 TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B
CITY OF CUPERTINO
FURNACEAC
CUPEkTINO FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
AIR
CONDITIONING
FURN/AC
1 BCAIRHAN
Commercial A/C Units <= l Ok CFM
B
1 MCRAA
Commercial Mech Repair/alt/add
M
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICO
Seismic Commercial
B
1 PGASCOM
Commerical for e i gas piping System
1-4 outlets
P
1 PGASRES
Residential for ea gas piping system
of 1-4 Outlets
P
1BPGAS
For each gas piping system of 5 or
more per outlet. C omm/Resid
P
1BREMAIRHAN
Residential A/C units <= IOk CFM
B
1 MRRAA
Residential Mech Repair/alt/add
M
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Seismic Residential
B
1 EPERMITFEE
Electric Permit
E
1 MPERMITFEE
Mechanical Perm: t
-M
1PPERMITFEE
Plumbing Permit
P
1TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B
CITY OF
.UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
112
PERMIT #
OWNER'S NAME:
PHONE # r/v `
GENERAL CONTRACTOR:
FAX # Ilu`l
-fJ
I am not using any subcontractors:-
--- / 7
Si;;mature Date
Please check avnlicable'subcontractors and comvlete the following information:
Owner/ Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
V'
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