10110124I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10810 PENINSULAR AVE
^WNER'S NAME: FARRER DAVID J
'S PHONE: 4087731847
1V LICENSED CONTRACTOR'S DECLARATION
L? c.
License Class /i C Z- Lic. # 7 4 9't< 77 1
Contractor j � r-+ J--(+ f;011 C- Date 11 I I S� hu
I 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 fie performance of the work for ch 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 macc}ue against said City in consequence of the
granting of this permit..A4&ion I'ly, the applicant understands and will comply
all non -points rce dgul#cns per the Cupertino Municipal Code, Section
Date i 1_je-10
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct 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
ify that I have read this application and state that the above information is
:ct. I agree to comply with all city and county ordinances and state laws relating
«^ building construction, and hereby authorize representatives of this city to enter
hn the above mentioned property for inspection purposes. (We) agree to save
-..demnify 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 regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date.
CONTRACTOR: AAA FURNACE &I PERMIT NO: 10110124
AIR CONDITIONING
1712 STONE AVE I DATE ISSUED: 11/18/2010
SAN JOSE, CA 95125 , PHONE NO: (408)2934717
F- r- r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH (— RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: REMOVE AND REPLACE FURNACE IN SAME LOCATION
Sq. Ft Floor Area: I Valuation: $3700
APN Number: 32603047.00 1 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:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should store or handle hazardous
material. Additionally, should I use equipm t or devices which emit hazardous
air contaminants as defined by the Bay,Xf-Si Air Quality Management District I
will maintain compliance with the C er 'no Municipal Code, Chapter 9.12 and
the Health & Safety Code ctro 5 25533, and 25534.
Owner or authorized Date:
r'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
'. FURNACE/AC /01 I Old 4
CUPEkTINO PERMIT APPLICATION FORM
APN #3 O3^ C4
Date: ; i -- u ► i
Building Address:
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Owner's Name:
Phone #:
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Contractor: A A A i=- L;, 1,JC c' c
Phone #: ; c<5 ? s- y) i 7
Fax #: 9' ')-?r 3 - 6. 7-I
Contractor License #: % -7 1
Cupertino Business License #:
Contact:C' C �2 •C ri< �"2 r;�
Phone #: Ll
Fax #:
Building Permit Info:
Elect ❑ Plumb ❑
Mech
Residential
Commercial
Job Description: j< y �'1 : ti`s u S1 �� ,' t c : r ; n, > .�, , ,� �> _,_. <� 0—
For Residential Installations:
Attic ❑ 1" floor Ea'
2nd 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: i 3 Je & I"C Type of Construction (Usage Class):
Strapped El On Platform 11 Bonded
New Location Replacement
Project Size: Ex ress ❑ Standard ❑ Laz e ❑
Major ❑
Valuation:
3 -k(,
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application or if applicable, include in plan set & the sheet index.
Revised 01/07/09