05060020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT WNTRACT„ORINFORMATION d
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT'°05060020
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
40
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0 0 0
=or, LICENSED CONTRACTOR DECLARATION
up I hereby affirm that I em licensed under provisions of Chapter 9(commencing Job Description
�W with Scotian 7tAt0) f Division 3 of the Business and Profusions Code,and my Heim=is
u noce nderc S ADD A/C & FURNACE
j p? License bass�.�{y.1s(�s�Li<.g
n H p Date ((•L—V] Contfuwr VLIFW_14� Luvw n.1 I?
ARCHITECTS DECLA ATIO
I undcrsund my plansshall be and u public rtemds
oats
Licensed Pro(cssi.nel
g
OWNER-BUILDER DECLARATION
3 0 0 1 hereby.(Seco on 1 em exempt from the Cssions Co e:Any c law for the
00 followwhich
garesa Perm(Secit t 7r,s1.5,Buadwr. and use damns Code:Any oily or county
$ which requires a Permit m cams the slur,improve,dcXrmil t file
repair any stremma
RE< poor that heltslAuaneealsaregmms the for such Contractor's
Law statement
time (commeficgwithSmuavtothepvvivinon3mecomanxrwanselaw(chapter9 Sq.FLFloor Area Valuation
u~S (commencing with Section.100)of Division3 the
theBusinessexeand
pton.Any
nvilationck)of
that he u exempt therefrom and the buts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit Subjects the spplican"o a civil penalty of 3 4�PI8Ql�e1D 0 Occupancy Type
.imam than five hundred Callan(ssBo). P y YP
❑1,es owner of the property,or .my employe.with wags as WeGxlc compensation,
will da the work,and the slructua 4 notintanded aroRemd forsak(See.706x,Business
and Poulmsioru Code:The Comracures Liam taw does not apply in an owner of Il Reftq�uired Inspections
prolan who builds or improves thereon,and who dmssuch work himself or through his /� '`7
own employees,provided that such improvements am not intended or offered for sale.If. �M 45JA—
however,the building or improvement is said within one yevr of completion,due owner, d�.p
builder will have the burden of proving that he did not build or improve fur purpose of
❑I.as owner of the progeny,am exclusively contracting with licensed contractors to ?rf'1•�
c000mct the project(Sec.7044.Business and Professions Code:)The Contractors U. BUIL
cave law docs not apply to an owner of property who builds or improves diction.and. 4ugL`�Y�s IL
who contracts for such projects with a contractor(s)licensed pursuant to du ConVacto's Aa
Lkcnx Law.
1 am exempt under Sec. .B&P C for this reason Yrj
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations: .
1 haw and will maintain a CertificiL of Causer”.self ivum tr
far Warr'sCompen-
salior.v provided for by Section 3700 of the labor Code,for the performance of the
ark for which this permis is issued.
J�t]9V/1 have and will maintain Workeri Compensation Insurance,as re t imd by Section
f hof the labor Code,for Ne Performance of the work for which thnpermit is issued.
My Wor�ke(Ja�C�ompesuatian Insurance carrier end P0"i nmMr
Camcr. 1661 Y/I{{K Policy Na.:
32
CERTIFICATEOF EXEMPTION FROM W KERS'
COMPENSATION INSURANCE
(Thu section need not becomplcud if the permit is for unchundmd dollars(SIM)
orh .)
1 cmd fv that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner an as to become subject o the Workerd Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenifieau of Exemption,you should
become subject to the worker's Compensation provisions of one labor Code,you must
.J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z "" CONSTRUCTION LENDING AGENCY
E+"0 l hereby affirm Nat thea is a construction lending agency for the performance of
W 7 the work for which the pemit is issued(Ser.3097,Civ,C.)
117 A lender's Name
lender's Address
Z
U 0 1 certify Nat I have mad this application and sats Nu the above information is
IL F cosec 1 agree to comply with all city and county ordinances and state laws relating to
DU building comwclion.and hereby induction uprexnmives of this city to enter upon the
r W above-mentioned Pmpeny for iuspeeti.n purposes.
(We)agree t0 save,indemnify and keep harmless the City of Cupertino against
rp liabilities,judgments,costs and expenses which may in any way accrue against said City
U in consequence of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU c IR ULATII NS.•.
_ Y(LI,�ZE'G[ Re-roofs
Signature of Applicam/Contractor Dau
HAZARDOUS MATERIALS DIS SURE Type of Roof
Will the applicant or future building occupant store or handle hatim ous mauriai
as dcOned by the Cupertino Municipal Code,Chapter 9.13,and He Health and Safety
,gliCode. 25532MI All roofs shall be inspected prior to any roofing material being installed.
Ycs
Will the applicaN
nt orfuwm.building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvardoes air contaminants as defined by thc Bay Area Air Quality Management
istricl7 all new materials for inspection.
❑Yes fN.
I have mad the haramnms materials requirements under Chapter 6.95 of the Cxlifor
Six Health&Safety Cade.Sections 15X15,75533 and 25534.1 umkrsural thdifthe building
does not currently have a tenana that it my msparionjiy in minty the occupant or the
m mcnbwhich most Wmetpoortoi laxim r.Certlficate fOaupancy, Signature of Applicant Date
e a 1'05 All roof coverings to be Class"B"or better
he,or authonvcd agentDate g
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
OB ADDRESS: PERMIT#
U 55 p4mm S0660 O
OWNER'S NAME: L PHONE
GENERAL CONTRACTOR: ? ` LMFAX #
I am not using any subcontractors: Ina
Signature Date
Please check applicable subcontractors and complete the follQing information:
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 Signature Date
CITY OF CUPERTINO
FURN
COF
CUPERTINOPERMIT APPLICATION FORM
APN # Date:
ayziZo
Building Address:
oa +n6vt
Owner's Name: Phone44-
ltd 46g) gal-qqs-3
o tractor: License#:
oma ✓ 70?3, �
ontact: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
Ivc Inc/ 7&rnaev
Residential fC] Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor❑
Adhere to min set back 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: Occupancy group:
ep P,q(PI y
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
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