07100006 CITX OF CUPERTINO ' ` '
BUILDIIVG DIVISIVN PERMIT �:���� ��� ���'�������"
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PERMIT NO.
BUILD NG DRESS:
�Obii5 RODRIGUES AV CONDITIC�NED AIR 07100006 •
PERMTT LSSUE DATE
OWNER'S NAME: ,
THOMSON RESIDENCE 1701 LI7'TLE ORCHARD ST 10/01 2007
SANITARY NO. CONTROL NO.
NE:
(408) 29�.-2220
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
0 0 0 0
i p � LICENSED CONTRACTOR'S DECLARATION JOU DeSCi1pU0❑
:� I hcrcby aCGtm that I am licenscd undcr pravisions oC Chap�r 9(commcncing
; Z� wiw Sccdon 7000) of Division 3 of ihc Busincss and Profcssiuns Code, and my Iiccnsc is REMOVE ��I�TD RE P LAC E FURNAC E
?� y in full Corec and eftec� -Z
�� Z Licensc Class ���(Z— L�. �► i '1� �{ G '
; F p Datc � n�— Conaactor _��,,�'r�fN_ � a, �L1�Y
� ARCHITECI'S DECLARATION
i a 6 I undcrstand my plans shall be uxd as pubiic rccords
)yU
: Q y Liccnsed PmCcssionai
�}�
OW NHR-BUILDER DECLARATION
! hcrcby alfirm �hat 1 am cacmQt Gum ihc Convactars Licensc Law far �hc
� p O Collowing rcason. (Sccrion 7(131.5, Business and Profcccions CoJc: Any city or county
�,°, � which requires a pertnit tu cnnswct, aitcr, improvc, dcmolish, pr repair any structurc
prior W i�s iscuancc, alsu uires thc a licant for such rmit ta filc a si ncd sWcmcnt Valuation
'_ z� `� D° �` g ;;q. Ft. Floor Area
< tha� hc is liccnscd pursuant to thc provisions o( ihc Contractur's Liccnsc Law (Chaptcr 9 $ 6 5 3 2
4 H$ (commcncing wi�h Section 7000) of Division 3 of thc Busincss and Profcssions Codc) ur
,u, � r. that he is ezempt thcrofrom md the bssu Cor the allegcd eumption. Any violarion of
Section 7031.5 by any applicant Cor a peimit subjccu the applicant w a civil penalty of ./�� NUm}�er Oeeupaney Type
nat mo�e than five hundied dollars (SS00). 3 S 9 1 O O S f) V
❑[, at owncr oC tf�e pmperty. or my employces with wages as their solc compensauon,
wilt do the worlc, and Ihe suucture is not intended or affe[ed forsale (Sec.7044, Busi�ss Reguired Inspections
and Protessions Code: 'It�e Canuactor's License Law docs not apply w an ownu of
propeny who 6uilds or improvcs thereon, and who does such wort himselCor �hrough his
own employccs, providcd U�at such improvements are noe in�ended or o[fered fm sale. [[,
however, the building or improvement is sotd within one year oC completion, the owna-
builder will have the barden oC proving �hat hc did not build or improvc [or purpoae of
sale.).
� 1, as owner of the propcny, am exclusively convacting wilh littnsed rnnuxtors to
construct the pmjeM (Sec. 7044. Business and ProCessions Cade:) The Conuacmr's Li-
ccnae Law docs not apply lo an owner of propeny who builds ar improves theieon, and ,
who conuacts for such projec�t wi�h a conUactor(s) licensed pursuant to Uie Convactor's
License Law.
❑ 1 am uempt under Sec. . B dc P C far �his reason ,
Owna Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty o[ perjury onc of the (ollowing declarations:
❑ I hs�e and will main�ain a Ccrtificate of Conscn� to self-insure for Workers Canpen-
ution, u provided for by Secrian 3700 of the Labor Code, for the performance of thc
work for which this pertnit is issucd.
I have and will maintain Worker's Compensation Insurance, as rt�yuired by Section .
3700 oC ihe Labor Coda Cor ihe performance of Uu work for which this peemit is issued.
My Worke�s Compensa�t carticr and Policy number aze:
Cartier. �LQ b 1'6 C> ��]' C7� �Policy No.: /'�f�1/1 � �''Y
CERTIFICA7'E OF EXEMP'!'ION FROM WORKERS'
COMPENSAT[ON 1NSURANCE
(This scction necd not be completed if the pecmit is for one hundred datlus (E 100)
or lcss.)
I ceni(y thxt in thc performance of thc work for which �his permit is issucd. l shall not
employ any person in any manner so as to become subjec� �o thc Workcrs Compensatian
Laws of Califomia. Da�c
Applicam
NOTICE TO APPLICAM: If, af�cr making Uiis CcrtiC�ca�c of Excmption, you should
bccome subjcct to thc Workcr's Compcnsation provisions ot Nc Labor Codc, you must
� O fonhwith comply with such prpvisions or this permit shall6c dccmcd revokcd.
z "" CONSTRUCTION LENDING AGENCY
[-�.i ►�-� I hcrcby a(lirm ihat thcre is a conswction Icnding agcncy (or thc performarMC uf
(Y., � thc wurk far which this permit is issucd (Scc. 3097. Civ. C.)
W Q Lendcr's Namc
? z C.cnders Address
V � ► certifY Iha� 1 havc rcad lhis application and siatc lhat Ihc abovc infortnaliun is
w �-' cortcct. 1 agrce to comply wi�h all city and county onlinances and state laws celaung w
0 U building conswction, and hcreby authome represcnu�ivcs of this ci�y to cnlcr u�n thc
� W abovrmcntioncd properly for inspccuon purposes.
a (We) agrce to save, indcmniCy and kccp harmless the Ciiy of Cuperuno against
H � liabititiu, judgmcnts, costs and expcnscs which may in any way accruc against said City
V z in consequencc ot the granung oC ihis permit. DaLE
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: -
SOURCE REGULATIONS.
Re-roofs
Signatureo(Applicant/Contracwr Da� T of R�of
HAZARDOUS MATERIALS DISCLOSURE }�]�
wll Ihe applicant or futurc building occupant storc or handlc harardous matcriil
u dcfincd by the Cupertino Municipal Codc. Chaptcr 9.12, and thc Hcalth and SaRty
c«� .Scction25532(a)? All roofs :�hall be inspected prior to any roofing material being installed.
❑ Y� , .
� If a roof i:� installed without first obtaining an inspection, I agree to remove
wll thc applicant or [uw building occupant usc cyuipmcnl or Jcviccs which
cmi� harazdous air conuminan�s at ekfincd by the Bay Area Air Quali�y Managcmem all new m aterials for inspection.
Dcsvici?
❑ Ycs ��
f havc rcad ihe ha�ardous ma�crials rcquircmen�t undcrChaptcr 6.95 of thc Cali(or-
nia Hcalth & Safcty Codc, Sccdons 25505.25533 and 25534.1 undcrstand that iCihc 6uilding
docs not curtcntly havc a tcnan4 �at it is my responsi6ility to rro0fy Uic occupant a! Ihe
rcyu' ms which musl bc me( pri to issuance ot c r�a� ar o��,P��r. Signature of Applicant Date
� ���� v All roof coverings to be Class "B" or better
O or thorecd agcnt Datc
i
_�,� : CI`T� OF ��JPEl��'II�� 0� i OC> ��tr,
� -��` ���.i� �_��/�.�;
�►n oF
CUPEF�TIP�O PE�I'�' APPI�I�ATI�I� �O
Date:
_� # ��� ( C7 �U ��p � � � � � (� ' ��
Building Address: C � � S
206 ° J ��� e R �� c� � l�-1
Owner's Name: Phone #: �
� �hs�rnt�sc� � 36 - 3 3 l �
I r `a3�tra_cio� � 1'l��l�e: I.icense #:
�, `A- S 2-� (• Z22 � y S( 6 2 -
Contact: Phone: Cupertino Business License #:
c�(�� 2 �/ � �.i�-1 YY�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech �
Job Description: �
� r� c�e� � L�
Residential �_ Commercial ❑
For Residential Installations:
Attic � 1 S ' floor � 2 floor �
Adhere to min set back requiremen�---
For Commercial Installations:
°placement same weight � Additional weight (stnzctural calcs) �
�tructural Calculations required for new installation ��
New installation Plannuig A proval Required ❑ �
Cost of Project: Type of Construction: Occupancy group:
6� S�`Z • Z°
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location � Replacement�
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY En :rgy BUILDING
g��U� Fu� �nace MECHANICAL
BREMACOVER A/�� Unit > 10,000 cfin MECHANICAL
BREMAIRHAN A/�� Units <= 10, 000 cfin MECHANICAL
BREMRECEPT Recpfl, Switch & Outlets ELECTRICAL
BSEISMICRE Se smic Fee Res BUILDING
BSEISMICOM Se� smic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
J MPERMITFEE ME:ch Permit Issuance MECHANICAL
PPERMITFEE Phmbing Permit Issue PLUMBING
BPERMFEE Blctg Permit Fees BUILDING
BPLANCHK Pl�n Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING