05040179 • CITY OF CUPERTINO x
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION '
xFa�a`S- K Sffi x"..EA." S.as _s..aL.taN-
BUILDING ADDRESS: PERMIT NO.
A PERFECT CLIMATE 05040179
OWNER'S NAME: PERMIT ISSUE DATE
OSANITARY 0. OL NO.
NE:
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
sec, LICENSED CONTRACTOR'S DECLARATION
00
asF 1 ion? affirm mat I am lithe Bu under previous.cssorCbaper 9 my liecacing Job Description
Z,y with Section 7gK1)o(Division Sof the BusittusWProfrssiomcodc.and my ficcrLsc is f
5'q? n full force and cff t �zyyLjln
ii«n:ryc�l' - � uc.a 5 ADD A/C '
o Dam Contractor k not 4
Asshall use DECLARATION
w U 1 understand my plans shall be used as public rtords �
CLicensed Professional O`er
OWNER-BUILDER DECLARATION
aS I hereby err,.Nmx
at I am exempt from the Comars License Law for the
00 following reason.(Section 703I.S,Business and professions Code:Any city or Countyk m which requires a permit to emouuct,alter,improve,demolish,or repair any structure
to¢i prior Or its issuers,,,also requires the applicant for such permit to file asigued summcnt
< matheislicensed pum
ramWthe provisions ofthe Camractr'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuators -
yls-O (commencing with Section 7(W)of Division Sof the Business and Professions Cade)or
.a. $ that he is exempt themfrom and the basis for the alleged ea,mption.My violation of
Section 7031.5 by any applicant for a .I,subjects the applieanno a civil penalty of 3„WwT_d.T...tgrO 0 Occupancy Type
not more man five hundred dollars($500). YV 9�.Y CYf�O'
0 1,as owner of the property,or my employees with wages a their sole compensation,
will do me work,and fire structure is not intended or offered for isle(Sec.71144,Business
and Profcssiom Cond.:The Contractors LicerLx law docs nut apply to an owner of Required Inspections
property who builds or improves themon,and who dies such work himself or 0tmugh his
own employees,provided mat such improvements are not intend,d oroRered for sale.If.
however,or,holding.,improvement is to within one year of completion,the owners
builder will have rte bard,.of proving that he did not Wild or improve for purpose of
salt.).
0 1,as owner of the property,am exclusively contracting win licensed contractors to
consumer the project(Sec.7(44.Business and Professions Code:)The Contractor's Li.
mase taw docs not apply to an owner of property who builds or improves Merton,and
who concocts for such projects win a contraxor(s)Reseed pursuant to the Contractors
License law.
0 1 am cannot Or ler Sec. .B Q P C for this mason
Owncr Date
1373tWORKER'S COMPENSATIONDECLARATION
1 hemby"m under penalty of perjury,one of the following declarations:
1 Its and will maintain a Certificate of Consent to self-insure for Workers Compere
W
ioe,as provided fat by Section 37W of dte labor Cade,for the performance of the
rk for which this permit is issued.
1 have and will maintain Winter's Compensation Insurana,as myuimd by Section
of the labor Code,for the performance or the work for which this permit is issued.
y WorkcY penas�aatiionInnssumntt camicr and Policy�nuutm�ber�ert�����Qrtier. ororr Atp Policy No.:�J
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
OTU section need not he completed little permit is foram hundred dollars($I00)
or cas.)
1 cenify that in the performance of the work for which this permit u Voted.I shall not
employ any person in any manner ani as m become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenir¢ate of Exemption,you should
become subject 0 the Worker's Compensation provisions of the labor Code,you must a
.J O foMwin comply wire such Provisions of this permit shall be deemed revoked.
'Z CONSTRUCTION LENDING AGENCY
P4 I hereby affirm that then is a construction lending agency for the performance of
IX 7 the work for which this permit is issued(Sec.3097,Civ,C.)
W Q Lendcr's Name
=z 1<nders Adness
U Q I ferdfy that 1 have read this application and sue that doe above information is
W F c.bRcL 1 agree in comply with all city and coumy oNim.e,s and state laws rtled.,to
0U building convection,and hereby authorize mpresenutives ofthis city to enter upon the
r W above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
wF., r%j liabilities,judgments.casts and expenses which may in any way came agalnstmid City
f)Z in conacguence,of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREyPULATIONS, ^/
l/l ,0-Z 4 Y,(CLL,� y 28'Os Re-roofs
Signature of ApplieanUContnetor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant tar future building occupant store of handle hanardoua mucrial
M acfincd by me CupenMu Municipal Code.Chapur 9.13,and the Health and Safety
Codc.sa,eonass33(a)+ l - All roofs shall be inspected prior to any roofing material being installed.
pplica
❑Ys �No
Will the am or Tvumrc builJingmcupantuse cyuipmem or dcvi=3 which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distrix?
❑Yes 7yN
1 have mad rte bmartlms materials mquimmenu under Chariot 6.95 ofthe Califor.
ria Hcalth dr SxfetyCodc Section 255(15.2x533 arta 25534.1 understand that if the Wilding
does not currently hoe a¢rant that it u my Mponihility On mdfy the occupant of the
refidQtMents,which More heTot Pon rto' vmc faCcmricine 4cn..vSignature of Applicant Date
Ower or a.mmn.d agent Date All roof coverings to be Class "B"or better
Y
CITY OF CUPERTINO
FURNACE/ACOF
C1 OF
-UPERTINO PERMIT APPLICATION FORM
APN # Date: Ll
Building Address: _
Ib 3 irze, Lh
0 's Name Phone #:
se
�q c-
ontractor: hone: Licen #:
Vvr� e+ `� ) I - Rs s 931s
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
Add Al c-,,
Residential Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2"d 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:
5,5-7`f 0—
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN 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
f MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees q1 ,v BUILDING
BPLANCHK Plan Check Fee / ",, 0 ') BUILDING
BUSLIC Business License p BUILDING