05110128 CITY OFCUPERTINO v ut»x+Mx � ""'�"'
BUILDING DIVISION PERNIIT '�OI�TRAG°TOR''INI'ORMATFOPI
BUILDING ADDRESS: A & H HEATING PExmrt no.05110128
10445 BREWER AV
OWNERS NAME: PERMQ ISSUE DATE
MIKE SEAVER 770 CHESTNUT ST 11 /2-4/200c;
NE: SANITARY N0, CONTROL NO.
(408) 279-0722
ARCHRECffFNGINEER: BURRING PERMIT INFO
BLDG Its R.UMB NEC41
zL 0
±Oi> UCENSED CONTRACTORS DECLARATION Job Description
Id 1 hereby amrM that 1 un li¢�d.Mer PhtAmons.f Cbwsa 9(mmm,tewg ®®®
N SoctiDO7 )Of Dlvwon 3 Of Iht Bosions and PrefC6WW Colc.anti mar BURY
+� brwlram Mose _ B u7 REPLACE FURNACE ���®
2 x in full
Ctw Z K
Y D.m coaua,or nor
Ip( Ivndcnuad mY PWutlwl EAgcilrnzcrSD ublic rtsad rst��q(�aJw `0
sLLt; E; dPm(essiaaal T TO{�(p(�D
OWNER-BUnRER DECLARATION
I mmby aTirm that 1 m aetnpt Iran ton Contna,tws 1i¢na Lav far Be
no fallowing mason_(Sadon 70315,Baa—• and Ponfnsoa Cade:Any city a awry figB p 5 O
<$ rhich rcquues.P,wt m aawrun.aIle.knpmw,dwaW4 a mpair any sv.,mm RR��88
uz�
that
he issccn=d potaamWho,Pbo Liol of
Ct) p mitm fdcasipmd nautmm C3
< lda,mulimmd pSevunt ntm ofOnsbna 3a ft Business lianmlaw(Chapa9 Sq.Ft. Floor Area BV_al`iptiv11"
e 8 (cat he Isdng with Section 7000)of basis i 7 of lm Vd oaa and Pra(mimu Cade)a
mon 70315 by awn waw ros•basis is,
,PPneOw dw Wwwly or
r Occupancy Type
not mac m.n nap hwdmd dwl..a(:sora).
❑LWo Of the WOP,IY•as MY employaa wild nta as tura sate mmpravtiw.
will de the wak.arot the smsmae a not lntcndcd a Offerel fm sak(Sa 7041.Betio Required Inspections
and ptOf,,I.code Tho Conu.cnrs I.-nx Law don not apply n at Owns,a .
Pmptny who bwldiaimpO,v thesaq aM who daesach wont himseGa through has
Own ewp.,M p�lbu vch imp�haoa art not bhsa daOnad far sada.a,
la m .the buBLing or anpow is low within—I=ofcaaPkdo0.ton.
milder wiB haw 0c bavda Of ponvwg that no,did ant bwN a impure W iah o of
sale.).
❑1.as.of da popmty w aaclusrrJy ana='ting want nmtMod mnuacmrs to
mtaoun ton ionic,(See 7014.Bested and Ponfnsaa Cade:)The Ceoraemra U.
cera law data not apply m an Oma Of pOPetSY+to mildst a aaprara i1c..and.
won conaacu rat Mooch ion =withacavana(.)licensd Parsaao n the coca M
r law.
❑lam mwp wda See .B&PCfath1a.
Owner Dam
WORKERS COMPENSATION PENSON DECLARATION
I banby aff.,oder pemky ar K,)M,ate of ton oil wing dalaralOnc
Iham anti will mainwt a CaNfaate O(Cattamt to aB4asute For wog sConipcn-
130
on.as p W_cl for by Secdun 3700 of ton labs COde.fa ton petfatmata of lm
ok for which Nisi uis ic.tti.
f haw and vl maimain WOr 3 Gsnpatsalon Inauana,n rNwrtti by Sccuon
00 a Nc lab,Code,fa dm Pfamwi¢oftle.ak fa which Nu papa is'va I
u i.. /i I B�aZ Policy Na_!
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(nu,,coon tad aam compkmd 9 to PnvN u faooe hatotad doaas(SIOM
aka.)
1¢ fy Nat In Ne pmronnshac of Its vert fa wbicb Nis formal,is weed.1 shall tat
cmploy.ny persan In any aaaev a a In mrmoe sobimt In ton waaliaa'COMPentalen .
laws of Cwif.nai_Due
NOTICE
u
NOTICE TOAPPLICANT:If.cosavWlnk this p Cct o(of Latce on.yap,Intl
baarc subjm y ton Wlobt P C ohs or tifis ponvison.at ton Luba Cant.yap trout
.J O fathwiN eomplY with arN prvvulon a rile permu still m dr neat¢rateQ
z CONSTRUCTION LENDING AGENCY
Ea41 botchy althat chrt wttw
eu. uctkn ltndin{.{cncy ror tic PMT.— .
arm
> the wont rat whxb this p,mit I.iatc4(STI.3041.Civ.c.)
G Q L,ndaes Add=
Name
.7 z Lrnder
U O 1 c ulfy au,1 Imw mad tot appUcatim ab n•w Na the alone iafamuNo 6
II. !' Moon,,,1 epee m cewply with all city and comity adimaes and orae Ian helvi.,n
Cr'J building ct onan Mott,shot mmby authonre teprutnu,Nea of Nu city to u upon ton
0 aM,Mchioacd pORny for inpcction pwpaas
(Wc)n.n art,itotcmni(1 and Yap barmkMo ton City of COMM agaimt
rA liabili,ka,jo,:Mca.cosa tndcaptnoMwhkb,q In anY way aL4.c agaiMIL said Clty
U Z. s povrnii.
in
UNDERSTAconMeofoact=of the nNDS g of AND WILL COMPLY WITH ALL NON-POINT Issued by: Datec7d—
SOUR REGUf.ATIONS. �•'
1 Re-roofs f'2"
SI A HAZARDOUS MATERIALS DISCLOSU RE Dan Type Of Roof
Win de apg0ant a Imtac balding aaupatamc aharAk hmAms nuaenal
as defircd by do Cup uno M.nieipal code.Duper 9.11.and the HUINd Lf
and
Mock.o>ti.253324)7. All roofs shall be inspected prior to any roofing material being installed.
194- If a roof is installed without first obtaining an inspection,I agree to remove
Will ft col caot ar malum hitting-p"use cgwp�a&,Tion which
malt twatdws air ccau,tdmna a dcfined by the Bay A Au Quality Mawgcmen all new materials for inspection.
Dv ?
pm pfyti
I baw mad the hazardous materials mquitcttetm u Cbap G95 Oflbo CAllfa
not Hnith k Saf,yCado.Smiaru 755(15.25533 a.125534.1 undOaanci lhalrYm buDdiq
doe mat,.My here anus.Na it u my to onslMluy b notify the o..P.a ton
mat which mwtmtm pnarN o(a CrrnillomW aature of Applicant Date
ca4 � ��� ` D?3 ✓ All roof coverings to be Class"B"or better
Ow�m�aeNa .&It�t
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
L O 4 O-E-1 al e
OWNER'S NAME: L PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
661 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
_
Owner/Contractor Sign tune Date
CITY OF CUPERTINO OS
FURNACE/AC
�PE�Twa PERMIT APPLICATION FORM
Date:
v AP1V # 3c26 y o63
Building Address: /o
I t� —5
Owner's Name: J ( �._ Phone #:
Contrac r: Ci Phone: ^ 74-07 LicensevAI
Contact: 1 ✓ Phone: of Cupertino Business License#:
l�G � S
t
Building Permit Info:
41dg ❑ Elect ®/ Plumb L^}— Mech
Job Description: ELI,
1:= Residential Commercial F I
v' For Residential Ins al ations:
Attic M 1St floor Z"d floor❑
ere to min set back requirement❑
r Commercial Installations: ls�
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new ms�llation
New installation Planning A rova] Required
Cost of Project: �' Type of Cons ction: Occupancy group:
N 2_�
Strapped• LiOn Platform S Bonded 4•Ft. Floor Area:
New Location ❑ Re lacerrlent`R�
• Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING .
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License / BUILDING