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04040195 CITY OF CUPERTINO , ,�^n BUILDING DIVISION PERMIT CONTRACTOR INFORMATION U r fu, BUILDING ADDRESS: A PERFECT CLIMATE PERMIT"04040195 22274 C OWNER'S NAME: PERMTf LSSUEDATE EDWARD DALY 10570 S DEANZ-A RINE) 04 /29 /2004 ONE: SANITARY NO. CONTROL NO. (408) 861-9545 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Boa LICENSED CONTRACTOR'S DECLARATION Q Q wp I hereby affirm that I am Wchurod under provisions or Chapter 9(commencing Job Descriptio a ��D IW with Section 7")orDNision 3ofthe Busineuand Professions Code,and my license is 9« imm�mnroanderf` Iy3tS� RF_ Vp CE FURNACE & ADD A/C MAY 6 2004 5 i Li<cnu CI rs Lic.x .A_SyLL p Daw Contracte -�✓ 1 'y AR HllW usSDELLA ATION it U las unJ my plans shall M1e used Or public reeoNs ��®�� Zyr 3 LicenscJ Pmfcssional OWNER-BUILDER DECLARATION .�i Y I hereby affirm diel I sm exempt frum the Contractor's License Law far the o O following reason.(Section 703 1.5,Business and Professions Code:Any city at county K$ which require a P.it w construct,alte,impmw.demolish,or¢Pair any structure w—'^ prior to its issuance.also requires the applicant rot such Permit to rile a signed summon that he is licensed pursuant o the Provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation c,FG (commencing with Section 7000)of Division 3 of the Business and Profmians Code)or caw,`;$ that he Or exempt Oomfrom and the basis for the,alleged exemption.Any violation of Section 7031.5 by any applicantfor•permit subjects the applicant to a civil Penalty of 34V&3Qllhl1er00 Occupancy Type not mom than five hundred dollars(5500). ❑ Lasownerof the pro 3murtmmycmployce witbwagex rage(hale compensation, will do Nesiork soda: he Contisnotintender Law it= mass,Business am Pmfedobu Cade:The Conmmor's ndwho Law dao oat apply to an owner of Required Inspections property who builds mimprovethinpoo.dwho..orin endo himselredWough his own employees,provided Our such imps mid wit am not Tender m ledon,for ask.If, however.the building or Improvement is halt within one Year or comoie for the°weep builder will have the burden of proving that W did not Wilt or improve for DuBose of sok.). ❑h a owner of the propenY,am exclusively conuaen.,with licensed comnmors to comwcr the Project(Sec.78 1.Business and Professions Core:)The Conuacwri Li cense law does not apply to an owner of property,who Wilda or improve Orman,and who contracts for such projects with a contrecu(s)licensed pursuant o the Contractor's License Law. ❑1 am exee[mppl-under Sec .B h P C for this consent 137W wner aft° Dale WORKER'S COMPENSATION DECLARATION 1 hereby affirm under Penalty of perjury one of Ne following declarations: I have and will maintain a Cenificam of Covent m self-insure for WoulumsCompen- ion,u provided fm by Section 37M or the Labor Cade,for Ne perrmmanm of the rk for which this Permit is issued. 1 have and will maintain Workcra Compensation Insurance,as required by Section of Ne labor Code,for Ne performance of the work for which this permit is issued. yWorkef1111s,AfCempevauon Insurance orcin and Policy rmberrrier. rl( pliq No.:^ ' ' •t I — Ie't CERTIFICATE OF EKE ON FROM WORKERS' COMPENSI INSURANCE (Thu section need not W completed if the Permit is for one hundred dollars($IM) or kss.) I certify that in in.prifimm eco of Ne work for which this Permit u issued.I shall not employ any pmson in any manner an as to become subject to the Workers Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to the Wmkcr a Compcmztion provisions of the labor Cost,you most . .JZ ficol comply with such provisions or this Permit a hall W cmmed revoked. Z O CONSTRUCTION LENDING AGENCY [-+ I hereby affirm that there is a construction lending agency for Ne Performance of LY, the work for which this permit u issued(Sec.3097,Civ.C.) fT] Loodues Namc = z Lender's Address C.3 C) I certify that I have mad this application and slow Nat the aW ve information is ly F' correct.1 agree to comply with all city and county monuments and state laws relating to 0U Wilding mnstmedon,and hereby auturim mpicunutives of this city to enter upon On }Ll shove-mentiuvd pnupeny for inspection Pmiwses. gy (We)agree to now.indemnify and keep hismless the City of Cupertino against FN liabilitie,Judgmcn¢com and cepensm which in any way ecmevgaimtsaid City U z in consequence ofthe gwming of apvmit. AP (CANT ND STAND WI MPLY WITH ALL ON-POINT $sued y: Date 2 l L ST RE L NS. t rf� VI Signanne or ADplicanuConuactor V Dau HAZARDOUS MATERIALS DISCLOSURE Type f Roof Will On applicant or future building Occupant store or handle havtduus matenal az refined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety otic.se❑c Year 3ss3zfa)? oN All roofs shall be inspected prior to any roofing material being installed. win On aPPlicam or future buildinfyccupent esu equipment or Devices which If a roof is installed without first obtaining an inspection,I agree to remove mit haraNnus air conwiinanu az fmcd by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Y ON. I have saJ the hasaNnus materials he ffiR .YS of rte Giifar nia Hcal"Safety Code, Nuns 15,35533dmi dic Idi J oo curtendy h rue( nem t i}s my rup. of c re uir n nor w� m sahmc (w iuvancy o V, Sign tureofApplicant Date Owncr or aunt ori7ed agent V Date All roof coverings to be Class"B" or better Community Development 10300 Torre Avenue ! i Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 UPEkTINO Building De artment JOB ADDRESS: � LI Cil � 1� � RMICL-1 0 T # L O I OWNER'SNAME: Dyl) PHONE # zrs(p —�fJ' ll GENERAL CONTRACTOR: ' C AX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date -� CITY OF CUPERTINO CITU s Ilk CUPERTINO PERMIT APPLICATION FORM APN # -3-2,6 13 Datef BuildingAd�lresq sGZh.� -�b� Owner's anj ,,),, n 0 Phone #: Contr ct�i(�� / is n #: G'I G` �Z� s Contac : Ph S� Cupertino B_ ine$s�c � #: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description- Residential e cri tion:Residential []—� Cormnercial ❑ 1� C For Residential Installations: Attic ❑ 18' 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- 2)10 roject- 2)1 U jype of Constructio Occupancy Strapped ❑ IOTT Platform ❑ Bonded ❑ Sq.Ft. Floor New Location ❑ Replacement ❑ Qty. A c' le Fee ID Fee Description Fee Group BENERGY Energy BUILDING 13REMFUPN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit> 10,000 cfm 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 2 BUILDING BUSLIC Business License BUILDING