04050056 i
/ CITY OF CUPEATINO
BUILDING DIVISION PERMIT CONTRAC�TOR�INFORMATION -
s n sy "
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO 04050056
2227c; CANY(W ITTEW RT)
1 OWNER'S NAME: PERMIT ISSUE DATE
• WILLY ARTER
ONE: SANITARY NO. CONTROL NO.
408 861-954
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=oo❑ LICENSED CONTRACTOR'S DECLARATION O O O
z b 1 hereby.from Our 1 am licensed under provisions of Chi 9(commencing lob Description
�Zw with Section7")of Division 3oflhe Business and Professions Cadcr,license is ���)L�f,' •-fa�
^<n• inful Imo an^ —Q �J 1 s�5 REPLACE FURNACE & ADD ASC
z n i Lieemse C1as Lie.
-s Datm - Can..,
GI t JUN 21 2004
�rJ' as HI'IECTS DECL} TION
J,myplans sylLhc
used as puhl'•retards
/C✓ A . l�
Gviis udlL'�Pmcssanal -
S OWNER-BUILDE DECLARATION MOLDING
iI 1 hcrcM1y affrtm that Iam exempt Tim dm Contractors License Law for the
00 fallowing reason.(Seetion 7031.3.Business and Prefessiom Code:Any city or county
x m fi which acquires a permit to consumer.alter,improve,demolish,or repair any structure
prior m its issuance.also requires lhamplicanl for such Permit to file.signed Itmmem
< thathcisiianmJPurwwunthcprovisiomoftheConlrxwr'aLamclaw(ChaPter9 Sq.Ft. Floor Area Valuation
p€0 (commencing with Section 7BBD)of Division 3 of the Business and Professiom Code)or
i that he is exempt therefrom and Ne basis for Ne alleged exemption.Any violation of wrn.n.�m
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penally of 3 Gt&$1]PIh®icr0 0 Occupancy Type
a.,moac then five bandied dollar.($500). P Y YP
❑I.a owner of the property,or my employees with wages as their sole compensation,
will do die work and the swcmm is not intended or offered far sale(Scc.7044,Business
and Pmfassiam Cade:The Commcmrs License Law does Out apply w an owner of Required Inspections
property who hold.arimprams thereat whadorssuch work himulfor through his
own employees,provided Nat such improvements arc not inmrudrd oroffered for sale.IL
however.die building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,as owner of the property,am exclusively contracting with licensed contnnora m
construct fee project(Sec.7Wd.Business and Profusions Code:)The Con ractor's Li.
cense law does not apply to an owner of property who builds or improve demon,and
who contracts for such projects with a cmtrachO(s)licensed pursuant toss the Cmumetar'.
License law.
FI I am eacmpt under Sec ,B&P C for this...
1371M
wner Data
WORKER'S COMPENSATION DECLARATION
1 hereby xRrm under penalty of perjury ow of Ne following declensions:
1 have and will maintain a Certificate of Consent to self-imus for Worker's Compen-
ion,as provided for by Section 3700 of the labor Code,for the performance of the
rk for which this North is issued. .
1 have and will maintain Workcls Compensation Insurance,a retuned by Section
of the labor Coo e.for due performance ofthe work for which this permit is issued.y WorkcYs Cent oratiInstill a umicr d Policynu amwrrico alicy No.: (y Y O
CERT FICATEOFEXEM ONFROMWORKERS'
COM PENSAO INSURANCE
mussenian wed not weampleecd if the permll is for one hundred dollus(SIM)
or leas)
I certify the,in the perfomunec of the work for which thi.Permit is issued,l shall not
,.play any person many manner an as to became subject to the Wmiccal'Comp mutts n
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the labor Code,you must
.J z forthwith comply with such provisions or this Knod.hall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
L+� I hereby affirm that Nem is a censtmctinn lending agewy far due perfammnce of
C the work for which this permit is issued(Sec.3097.Civ,C.)
W Lender's Namc
G I<aZ's Address
a z
V O 1 certify that I have mad this application and sum doer the above information is
L,, cored.I agree to comply with all city and county ordinances and sure laws relating to
OV building counteraction.and hereby tullo m representatives of this city to enter upon the
.hove-mentioned property for inspection purposes.
FC (We)agree to save,indemnify and kap Inundate;the City of Cupcnino again,
TA Iimilidcsjudgmcnu,toss and expesa which may in any way amue against said City
U in consequence of the granting of this Norris.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Si...I..of Ap,dicaaVCanmmar Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicator or future building uacupaerifnre or handle harardaus m tidal
as defined by the Cupertino Munieipal.Gade.Chapter 9.12 and Ne Hcalth and Safety
aur,sewanzssuan
❑Ya jpNm All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future b ildir :-r?P q p If a roof is installed without first obtaining an inspection,I agree to remove
y g u ant tau c vi mem or devices which g
not havardous air conumman . dcrmtd by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes �No
I have mass the W4dms mamrials rquimmenu unukr Chapter 6.95 or disc Caliror-
niaHealth&Secty Cade.Sm 25505.25533v 25534.Im&e Wtlfthe Wilding
cheated,...It,hams a mnanl WI it is acspo ity m notify the occupant of Ne
acqul nts which st he nuiLp. roan. . 2111n.oracu cep , l0 _�;rnature of Applicant Date
Owner or authorized agent Da c
All roof coverings to be Class"B"or betteryJ
Community Development
10300 Torre Avenue
✓ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRES PERMIT #
P-a-2-7St", VI�A&- C i D L4 D�S�CC)S�D
OWNER'S NAME: '4S,, t 40rs '� PHONE # $ (:LOUD -'� (0-7
GENERAL CONTRACTOR: ✓'tom - CA AX # ZtOt W
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' tion:
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
a
er/Contrctor Signa Date
u
CITY OF CUPERTINO
Y OF
CUPEkTINO PERMIT APPLICATION FORM
APN # .2� O0p Date:
0
Building Address:
2225
Owner's Name.. Phone #:
1 9 -7
Co ttor: Phone: nsq License #:2 }h�
Cont t Phone: „ �^ �5 Cupertino Business License #:
reA
Building Permit Info: ��'`�
Bldg ❑ Elect Plumb ❑ Mech
Job Description
au C✓
Residential V 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 ARproval Required ❑
Cost of Project:0 zJ Typ of Construction: Occupancy group:
(2 G.Cr
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location P Replacement ❑
Qty.
if-
Applj6oe Fee 1D Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfin 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
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