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CITY OF CUPERTINO
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DIVISION PERMITCONTRACTOR,INFgURMATIQN
BUILDING
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BUILDING ADDRESS:
A PERFECT CLIMATE
PERMITNO04020077
OWNER'S NAME:
PERMIT ISSUE DATE
VERA D
ONE:
V
SANITARY NO. CONTROL NO.
(408) 861-9545
CHITECffENGINEER:
BUILDING PERMITINFO
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BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I bercby affirm that I sm licensed under provisions of chapter 9 (commencing
p
inmsand Prufcssions Code, dmylicmacis
n force andenss —�,eg
Clear
]ZEpLACE FURNACE IN EXI STINo�gA�I ONenu
Da¢ Conley
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A CHRECTS DECLO(RATION
I understand my plans shall be used as public =in&
AUG 2004
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm thal I am exempt from the Contmcim's License Law for the
followingreasen.(Smal 7(131.5.Busin mdPNfcWom Cwk:Anyciryorc...ty
�' �Atl ®Ate'
Which ruqu;ros • permit m convect. ahm. improve, demolish. or repair any structure
B� Ito V'
poor In its Issuamcc.alsu requires the appimm, forsuch Permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractors Licrnm Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division J of the Business and Professions Code) or
Nat be u <umpt therefrom and the beau for the alleged exemption. My violation of
3 81�P.dQVltfi11er0 0
Occupancy
p Y
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not come that live hundred dollars (M).
❑ 1, u ownu of IBe pmperty, m my employcm with wages u th,tr sole eompensadon,
Required Inspections
will do die work. and thestructure is mummeded ornRered forsek (Sec. 7W. Business
and Professions Code: The Contractor's Licnme taw does not apply a an owner of
propectywho W;Idsori.,.. thereon, andwhet dausuch wort himttlfor through his
own employees, provided that such improvemenuarc notinermed oroRCmd for tale. If.
however. the Wilding or improvement is sold Within one year of completion, the mvner.
builder will have the Widen of proving that be did not Wild or improve for purpose of
sak.).
❑ I, as owner of the property. am exclusively contracting with licensed comnclora to
mvuuct the projm (Sec. 7044, Business aW Prefossions Code:) The Contractors U.
cove law dam not apply to an owner of property who Wilds or improves Neuron. and.
who contracts for such projects with a eomuseror(s) licensed pursuant in the Contractor's
License Law.
❑ 1 am exempt under Sec . B & P C for this reason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby afro under Ismaili, of perjury one of the following declamations:
I have and will maintain. Cert;rima of Consent 1. self -insure for Workers Compen-
sslion, ss provided for by Section J]00 of the laber Cede, for the perfonnaorc of the
work for which this permit is issued.
as required by Suon
❑ 1 have and will maintain Worlds Compensation Nn Sum it
3700 ofthe labor Code. for the performance ofthe worts for which this permit is issued.
My Worker's Compensation Insurance carrier and Polity number am:
Carrier. Policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Nis suction need not becomplelcd if Ile permit is fearanchundreA dollars (SIM)
or teas.)
I certify, that in the performance of the work for which this Permit is issued, l shall not
employ any person in any mannersr as to become subject to the Worker' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject m the Workers Compensation provisions of the laMmr Cook, you must
foMwilh comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ibereby affirm that there is a construction lending agmey for the perfurmanceuf
the Work run which thin pevnil is issued (Sec. 309'1, Ci, C.)
Lenders Name
Lenders Address
I rectify that I lase reed this applicmion and sat, lost the aaum information is
correct. 1 agree to comply with all city and county ordinances and sure laws relating to
building constrction, and hereby au hour reprmentadves of this city w COW upon the
aWVe- mentitamed property for Inspection purpox&
(we) agree re save. and LOOP hay they City l
ju costs and expenses in An
grim and expenses Wh ;Ch ray ;n any Way aLCNt againstmeld Glly
10Ofe against id cis
;INmuenco
ine of
Aconsequence of the granting of Nis 1
D
APPLICANT UNDEgSTANDS AND LL COMPLY WITH ALL NON- POlrrri
SI�RCE4 U A ONS.
Issued by: Date
((��((//I✓�L. (/
Id
Re -roofs
Signature of Ap,lican ✓Cmmx mf Dam
HAZARDOUS MATERIALS DISCLOShF E
Type of Roof
Will the applicant or future building uccupam norcor a IL hvardaus material
ss derined by Ibe Cupenime Muni 1 Code. Chapter 9.12. the Health and Safety
CWc. oYmn 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining n inspection, I
Will the applicant or fulu uilding occupant use equipment or devicm which
agree to remove
g p g
mil ha.&.a air conmmimm as defined by the Bay Area Air Quality M ... Sumer,
all new for inspection.
Districst
materials
❑Yon ON.
I have read! lhehv4NOUSmaar)5,253and
the Glding
nix Health Codc,Smions 23505.255JJand25534ty,provorytao .p Wilding
25534.1 maknon shat if
ncoI
dies font cuncndlf have a enant. th it u y rmponsibilimY tp notify tic occupant rf
rec� emnws;'hmut},bfm nrm; angers IrMaxnrarrpyl(y, Lr'
S*nature of Applicant Date
All roof coverings to be Class "B" or better
Owner or aulhomed agent Dom
CITY OF
�CUPEkTINO
CITY OF CUPERTINO
FURNACE /AC
PERMIT APPLICATION FORM
- �Y 7
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APN #
Date:
Building Address: \ �L��D
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ee rou
BUILDING
Owner' N rr J+1\ 0.iP
�c/torP
P40$
Co Phone:
G\, O r cic -g5`45
License #:
�
Contact: Phone:
Cupertino Business License #:
A/C Unit> 10,000 cfnT
MECHANICAL
Building Pennit Info:
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
Bldg ❑ Elect 421/ Plumb ❑
Mech 2--
Job cri tion:
Residential Commercial ❑
For Residential Installations:
Seismic Fee Res
Attic ❑ 1s` floor ❑ 2"d floor ❑
Adhere to min set back requirement❑
'For Commercial Installations:
Seismic Commercial
-
Replacement same weight ❑ Additional weight (structural calcs) ❑
_
tural Calculations required for new installation ❑
1
installation Plannir royal Re uired ❑
of PrO,ydect: Type of Construction:
kew d-2ved
Oc u-7
On Platfonn ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Plumbing Permit Issue
p he ble Fee ID Fee Descri tion F G
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B NERGY
P
Energy
ee rou
BUILDING
REMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit> 10,000 cfnT
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
Bld Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business Licen 1
BUILDING
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