10100034 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 10135 MC LAREN PL CONTRACTOR:VALLEY HEATING& PERMIT NO: 10100034
COOLING
?ER'S NAME: TOM LUI 1171 N 4 TH ST DATE ISSUED: 10/04/2010
OWNER'S PHONE: 4085104272 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
d LICENSED CONTRACTOR'S DECLARATION r F
/1 �y BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class CZ Lic.# D 54G
MECH RESIDENTIAL COMMERCIAL
Contractor V4&n, f•� Date AZY1
Zo
I hereby affirm that I am license under the provisions of Chapter 9 JOB DESCRIPTION:FURNACE REPLACEMENT
(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. Sq.Ft Floor Area: Valuation:$3198
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. APN Number:31621052.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DYS FROM T CALLED INSPECTION.
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 Issued byA • f O Date:
9.18. �c �,
F +ure Z�4.t.1 Date xy� [
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
P Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authe agent �_ �_
Compensation laws of California. If,after making this certificate of exemption,I 5if% c ate:bo 5!
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
he above mentioned property for inspection purposes.(We)agree to save
nify and keepharmless the Ci of Cupertino against liabilities,judgments,
costs,and expenss which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
Building Department
City Of Cupertino
Is 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: �j tKC L r e� c 71 PERMIT# ( � `'' ' `—' (-
OWNER'S NAME: ,?,t L PHONE # -4& SIO — 4Z7 —214 7
GENERAL CONTRACTOR: Valte �.Co BUSINESS LICENSE#
ADDRESS: &/7( K, 4ftk SrCITY/ZIPCODE: 542
*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 SUBCONTFACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. k 5' l� 0 TQC
I am not using any subcontractors:
Signature Date
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
CITY OF CUPERTINO
FURI`IiITACE/AC
CITY Of
CUPEkTINO PERMIT APPLICATION FORM
APN# � � ? � Date:
Building A dress:
l0 f 35 tCc Lame•,
Owner's Name: Phone#:
Tp n L t 6 -`f2 - 21c
Contractor: l 1 / Phone#: q&g— 7q y-(�Z qd
t/a Ile �e�f C �c�1, Fax #:
Contractor License#�: 1� Cupertino Business License#:
Contact: _ Phone#: 40,1--24q (1,Zy 0
Fr {`c Fax#:
Building Permit Info:
Elect❑ Plumb ❑ Mech
Residential Commercial ❑.
Job Description: C
For Residential Installations:
Attic ❑ 1St floor�' 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: Type of Construction(Usage Class):
-4-t-
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement ❑
Valuation: J� 3 r Y F—
Green Building: Must attach Green Building Cl.eck list to this application