10060055 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19784 WINTERGREEN DR C011TRACTOR:PRIME MECHANICAL INC PERMIT NO: 10060055
OWNER'S NAME: CITY OF CUPERTINO 162 50 RAILROAD AVE DATE ISSUED:06/09/2010
TR'S PHONE: 4087773407 MO2GAN HILL,CA 95037 PHONE NO:(408)782-8058
❑ LICENSED CONTRACTOR'S DECLARATION JOIE DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
WIL SON PARK-PARKS&RECREATION BLDG-INSTALL NEW
SPLIT SYSTEM HEAT PUMP A/C HEATING SYSTEM IN PLACE
License Class Lic.# OF OLD A/C SYSTEM.(CITY JOB-NO FEES)
Contractor Date
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: Sq.Ft Floor Area: Valuation:$15000
t. 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. APN Number:36910001.00 Occupancy Type:
2. 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. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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 180 DAYS FROM LAST CALLED INSPECTION.
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, Iss ied by: Date:
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. RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
insi alled without first obtaining an inspection,I agree to remove all new materials for
inspection.
L OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
1. 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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed contractors to I h ive read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). Ca ifornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
cor npliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I hereby affirm under penalty of perjury one of the following three declarations: Sal ety Code,Section 25532(a)should I store or handle hazardous material.
t. I have and will maintain a Certificate of Consent to self-insure for Worker's Additionally,should I use equipment or devices which emit hazardous air
Compensation,as provided for by Section 3700 of the Labor Code,for the coutaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
2. 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 . O Te or authorize ent:
permit is issued. Date:
3. 1 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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I I h:reby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed,/�j Le rider's Name
revoked. �"`�
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION
correct.I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Li sensed Professional
ipd-ninify and keep harmless the City of Cupertino against liabilities,judgments,
ind expenses which may accrue against said City in consequence of the
gi—ang of this permit.Additionally,the applicant understands and will comply with
all non-point source regulations per the Cupertin Municipal Code,Section 9.18.
Signature Date 6 l�
�.J
CITY OF CUPERTINO
FURNACE/AC
CUPEf�TINO PERMIT APPLICATION FORM
APN # �/ � � /� Date:
Building Address:
Owner's Name: Phone#:
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Contractor: Phone#: d'7 7 _ 6,3 S _ 'Y3,,'cP
P/2 /iy� /Lie c�,q ri �cq � Fax #:
Contractor License#: 1WCupertino Business License#: 2Y /
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Contact: Phone#: 4/o0'- o79 3"'- dzt>.3.6
IFC eA (� �^'.r�o w Fax #: 7 77 -
Building Permit Info:
Elect 0 Plumb Mech JE
Resid6ntial I Commercial NJ
Job Description: s ) ,7 -ryrd le -I e*7` 1.2 0AY
/ Ic - A eq �� s `7l�er� i p /,cI ee o{ m X00 sy,r�e,y t3A
For Residential Installations:
Attic ❑ 1St floor 2"d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ EWditional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project:X Type of Con Aruction (Usage Class):
om
�s paa v
Strapped ❑ On Platform ❑ Bonded New Location,0 Replacement
Project Size: Express ❑ Standard ❑ Lar e ❑ Major❑
Valuation:
! g" oar
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09