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12110001 (2) CITY OF CUPERTINO BUILDING PERMIT RUILDING ADDRF-SS: 10641 CARVER DR CONI"RACI'OR:PELLE HEATING R AC INC PF-RMITNO: 12110001 OWNER'S NAM Ii: LUCIA MADRID 3728 C CIIARTER PARK DR DA'Z'E ISSUED: 11/01/2012 OWNER'S PHONE-: 4084904756 SAN.IOSF-.CA 95136 PHONENO:(408)978-7060 ❑ If CON'rRAC`rOR'SDECr DECLARATION BUILDING PERMIT INFO: BLDG r ELECT _ PLUMB License Class e. ' 2y Lie.H 09 ( --''JJ-- q-, D1 F.C11 r RESIDENTIAL r__, CONIDIERCL\L r Contactor"k"-< w�l+;f 00 /2, Date 1 hereby affirm that I am IicemiseJ under the provisions of Chapter 9 .JOB DESCRIPTION: REMOVE AND REPLACE EXISTING WALL FURNACE (35000 (commencing with Section 7000)of Division 3 of the Business& Professions BTU) Code and that my license is in full force and effect. RTU) 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 Sq.FI Floor Area: Valuation:$1500 permit is issued. .\PI'LIC\N'P CIiR'I'IPIC,\'PION ANN Number:37534048.00 Occupancy7'ype: I certify that I have read this application and slate that the above information is correct. I agree to comply with till 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless(lie 6tyofCupertino against liabilitics,judgments, WITHIN Igo DAYS OF PERMIT ISSUANCE OR costs,and expenses which may acerae against said City in consequence of the granting of this permit. Additionally,the applicant understandsand will comply Igo DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations r th upertino Municipal Code,Section Issued by: /� -�/ R%G// Date: I/•/ •/ Signature Dme ❑ OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Lain formic of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of property,or my employees with wages as their sole comfensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as Omer of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BEATER 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 HA7.ARDO IS MATERIAL S DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Ilealth&Safety Code.Sections 25505,_25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hanmrdous material. Additionally,should I use equipment or devices which emit h: ,ardour air permit is issued. contaminants as defined by the Ray Area Air Quality Management District I will I certify that in the performance of the work forwhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,.) become subject to the Worker's Compensation provisions of the Labor Code,I must Owner r Ihli z ,em forthwith comply with such provisions or this permit shall be deemed revoked Date: -(Z CONSTRUCI•ION LENDING AGENCY A('PLIC\\I'CFR'I'IFICA'I'ION I certify that I have read this application and slate that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordin aces and state Imus relating lot which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the graining of this permit.Additionally,the applicant understands and will comply ARCI I1'fECI"S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Sectiat 9.18. I understand ry plans shall be used as public records. Signature Dale Licensed Professional .�� ✓c�l� - IZII � v � l GENERAL PERMIT APPLICATION M E P - C COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 R A ' A CUPERTINO (408) 777-3228 • FAX(408)777-3333• buildinCSCUDenino.oro eI\9/' va IC ❑?LbNSING CHAMCAL ❑ELECTRICAL ❑N.ISCELI.ANEOUS PROJKTADDREssw' y /� Y�f1�n .317- �\ ONZX NAME PHMAM s;x ,6DDRE� �NeC-\2 I cr TATEza v Oq C7�/`1 I FAX CON--rAC(TT NAME lJ Plio.-E E-NA,1 STREETADDRESS CIY.TATE ZIP FAX PrOWNER ❑ O0.TC1-BUTLD ❑ ONRlERAGE.NT' 9ZONTRACTOR ❑CONF =RACE^T, ❑ AAo-=1= ❑ aG:NBER ❑ D1-'iAPfli ❑ T1i,11 CONTRACTOR NAJ w� �c11 _ L7cl � 6ll F27 9U5.LIC: CDN.PMY NAME�� l-C 3 h ILIi'5'Ab-Jule srRL,3'D1 Sis-,, v-rtr�Y�.a.r- L� I crr.TAr,�/M JJ� 9 513 E� ARC.-EicCT/LWGB+c"1tc NAME DCENSE NUNS M- BUS.LIC k CAMPANY NAMEE-N.AD. FAX STRtCr ADDRESS MY.TATE,ZIP � I PHONE US'c OF FDaDUPL9t ❑ MULTI-F,JMY I PROTECT W WBDV,ND ❑ 1^S I PR0.'SfIN YS I Li Tlv 6'.DG AN ❑ 1'FS RUP.-I)va: CONNZRCL) UR9ANW ACE AR:a NO FOOD 7AN'c NO flCH19t HOME7 NO DESC]UFnON OF WORK }L L--L.11L1 Tww^C.Q J TOTAL VALUATION: I/�� O �-� I REC'cIVED BY: ✓_ /- By my signature below,I cetiry w each of[he following: I am the property owner or authorized agent to act on the properyryowner's behalf. I have read this application and the information I have provided is c L I have-ad the Des ion of Work and verify it is acc=u.. I agr eq to comply with all applicable local ordinances and state laws relating m building co non, a ori -r re n - of Cupertino to enter the abov:.i/den•' ed pro c:,j for insnecdoa pvi oses. Signamm of ApnlicardAgene Dax: �( SUPPLE INFORMATION REQUIRED OFFICE USE ONLY y OVER-THE-COUNTER r ❑ EXPRESS rj ❑ STANDARD J a ❑ LARGE 5 ❑ MAJOR M'?AfscApp_2011.doc revised 06121111 FEEMO■■■■ ■MINN ■■■ ■■■ MI ■o■E■E , , ■■■■NEON IMMl■� ■■■ \ ■N■iNON■ o EEMMEMIN M M ■ N■ •N■ O■■EMEND■■■■NN■■■EN N■ ■ ■■ � ■ ae ■■■NNE■■■■EN■■■ ■■■ , ■� NO ■■■E■ON■E■■EEE ■O N■E E■■■O■■E■E■ONE■■E■ ��- EO N ONN■■E NEE■■N ■ ■ ice, ■■ ON - ----- N ■N■■■E■O■■■EE■E■■■■000 ON ■ ■■■■■■■■■■■■■■■■O■■■ -- ■ ■■■ ■ NoO■ N■OMEN E■O ■ NEON - ■NNONE N■E ... ... N■ ■ N■i ■ ■ ■N ■■NEO■EOO■O Q� OEM No ■EMNON ■O ME No ■■■ONO ■E NONE ■ ■ENO ■■EN ■E ■ ■E■E■E No MEN NO ■E ■ EO■■E■NEN - ■E■O■■■■■■E ■ .Ns �I■ OMEN ■E■NON ■ man IRS NEON ME EO■E■ONO ■O N■ ■ ■ ■ ■ OOO■ ■ ■ ON■■■■�■■m Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Teleplione: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: / PERMIT# ORD OWNER'S NAME: r /7«c f PHONE # - 706 0 GENERAL CONTRACTOR: C4 h �/Zo ti BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: S *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUB T T YE OBTAINED A CITY. OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: l� l 2— Signature Signature ate 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 Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date