03090002 CITY OF CUPERTINO 11,rt+ 111m,"_ Tt 1
BUILDING DIVISION PERMIT �..�C0NTRACT0R INFORMA 101 R,
BUILDING ADDRESS: A PERFECT CLIMATE PERMITND03090002
NER'S NAME: 10570 S DEANZA BLVD PERMITISSUEDATE
PHONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0
i00 LICENSED CONTRACTOR'S DECLARATION ,
F lob Description
1 kmby art,,.Nal I am licensed under provifiom of Chapter 9(commencing
`uf with S.mian7(��(Division 3 orthe Business andPofessinna Code,an my license is o
in mnIne.n1 a� I STALL ASC - �//
'nos License l s % Lie.I , ,
nF DBIC Canlf+Cbf - 3
Aeqq ARCHITE RA IO
8 I understand my plans shall k used u public records
t'as O Licensed PntPcssionel
5
OWNER-BUILDER DEC.Contractor'.
ON
f I maxocroby.(Erre Nal 1 1. exempt(ram the Cessions o :Any c ty o far the
followm whichingr.aana.(Scedon conson5.ant,
t,alter, end ver dcinns Code:Any city or county
which requires a issuance.Also re cores the alter,improve,h Permit t or e a sig any avuctum
�y Prior It,ORL he is
aluantto requires Applicant rorsucMe CohpermrLmcanse LAW(ned Chapter
1- (commencing
esleaguespSection7 h)provisions of NeeBuusor'aUccaxlsw(Chspmr9 Sq.F[. Floor Area Valuation
(comhe I.exempth Section 70W7 of basis
r M Al eged Business and t PrOftesson.Any vi Cmle)or
u��
that he u exempt Ncmfmm and Ne bmu for Ne alleged exemption.Any violation of 36205004 . 00
Section 7031.5 by Any Applicant for permit subjects;Ne applicant o a civil Penalty of APN Number Occupancy Type
nos marc Nan foe hundred dollars(S300). - - --- -- --- --
❑I,u owner ofthe propeny,army.mployces with wages As their sole compensation, ��1].::'T777��.��r..:`(�R1pT/�7�7��
and Pr Newark.end e: he Com is em's License
Law
does
n t apply 7051,owner
or — G TFEEI`Hfs3's&6ns
and eny wh ons Calc:The Conhemon,License Law dors not apply so an owner of llfGi.-. _-
pmpenywhobulld+orimproveNarcan,and who dosvuchwork himselforNroughhis � 501 — FINAL EL CTRI AL ENERGY
own employees,provided that such improvements an,not intended oroffered for nit.It. 505 — FINAL ELECTRICAL
however,Ne building or improvement is sold within ane year of compledon,Ne owser-
builder .will have OR Wrdcn of proving Nn k did sol Wild or improve for purpose of
Rale,).
❑1,as owner of Ne property,em exclusively convecting with licensed contractors to
convect Ne project(Sec.70 ,Business and Professions Cade:)Tlx Contractor's Li.
cense Law does not apply to an owner of property who Wiids or improve thereon,and
who contracts for such projects with a eonvacsor(O licensed pursuant to the Canuadar's
License Lew.
❑I am exempt under See ,B&PC for thi+reasen
ser Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury aro of des following declarations:
❑Ihave and will maintain A Certificate ofConsentto self-insure fm Worker'+Compem
cation,As provided for by Section 37M of Ne Labor Code,for Ne performance of she
work for which this permit is issued.
❑1 have and will maimaln Workers Compensation In....cc,As Required by Section
3700 of the Labor Code.for Ne performance of the wart for which Nis permit is issued.
My Workeri Co tp Ration Insurance carticr d Policy numk am'
A' APolio.:
CERTIFICATE P1701fFROMWO KERS'
COMPF.f TION INSURANCE
(T os sectionreed no,k completed if Ile permit Isles..hundred dollars(510()
nr leu.)
1 unify Net in she pofnrmance of Ne work for which this permit is issued.I shall nut
employ any person in any manner an As to become subject to the Workers'Campensa0on
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cerlifiaes of Exemption,you should
became subject to the Worker'+Compensation provigOol of the Labor Cedc,you most
Oforthwith comply with such provisions m this Permit shall the deemed revoked.
y Vy CONSTRUCTION LENDING AGENCY
-+ I hereby affirm Nat Neu is canswction lending agency for she performance of
Me work for which OR permit 11 issued ISa.3092 Civ.C.1
YQ Lenders Nam.
z Lender's Add.
I certify Nat 1 have rad this application and sues Nat Ne Above information is
correct.I agree t0 comply with all city and county ordinances and stale laws relating to
building construction,and hereby auNorim representatives of this city to colo upon the
above-mentioned property for inspection purposes.
y (Wc) a It cave,indemnify and keep harmless Ne City of Cupertino against
V) liebilitla.j g nts,cosu m0tm ey,which mayin anywayicoue against aid City
J in conuqu cc fNc t of this Permit.
APPLICA ND STA SAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO RC GUL 10
Re-roofs
Si cure f pl nvsel Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
11 c applicant ser fusurc building Occupant a tam car handle hmudousmarcrial
dc0ne y Ne Cupertino Mu typal,Code.Chapter 9.11.and the Health and Safety
Seeders 255320)+
❑Ye+ No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future ilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haxardtms air conlaminanb As defin.d by ale Bay Area Air Quality Management all new materials for inspection.
District
❑Yes
I have read the Waanb amaesrial+requirements under Chapwr6.95 of the Califor.
nice H..lth&Safety Code.Sodom 25505,15533 and 25530.1 untied Natif de Wilding
dors sol currently have a morel, 6 my rcaponsihility m nntil'y des occupant of Nc
requimmmosom,c uwkm its eof.ccrdfmamofL. c Signature of Applicant Date
0 toi ,m All roof coverings to be Class"B"or better
. CITY OF CUPERTINO
Item 1 of 2 PERMIT RECEIPT OPERATOR: quem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36205004 .00
DATE ISSUED. . . . . . . : 09/02/2003
RECEIPT #. . . . . . . . . : 22979
REFERENCE ID # . . . : 03090002
SITE ADDRESS . . . . . : 21430 COLUMBUS AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SKEELS V D AND SALLY A
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4971
RECEIVED FROM . . . . : A PERFECT CLIMATE
CONTRACTOR . . . . . . . : SMITH, BYRON E LIC # 21144
COMPANY . . . . . . . . . . : A PERFECT CLIMATE
ADDRESS . . . . . . . . . . : 10570 S DEANZA BLVD
CITY/STATE/ZIP CUPERTINO, CA 95014
TELEPHONE . (408) 861-9545
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BREMAIRHAN NO.UNITS 1.00 9.50 0.00 9.50 0.00
BREMRECEPT NO. OUTLETS 1.00 1.11 0.00 1.11 0.00
BENERGY PERMIT FEE 1.00 23.10 0.00 23.10 0.00
BSEISMICRE VALUATION 3,223.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
EPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
MPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
__________ __________ __________ ----------
TOTAL PERMIT 140.77 0.00 140.77 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL
• I CITY OF CUPERTINO
PERMIT APPLICATION FORM 0 3 o90v�a
APN# Date:
o yaa v3
Building Address:
Owner's arae:
S ' S
Contractor License #:
Contact. _ S Cupertino Business/ i ense #:
L4,5e? 92W
Building Permit Info:
Bldg ❑ Elect Plu b Mech
Job Description: ' �� /I c,
Residential 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
Cof Project: Typ Mns; ction: Occupancy gro r 2,
Stra ped On Platform onded LJ Sq.Ft. Floor Area:—
New
rea:New Location ❑ Replacement ❑
Qty. if
App ' ale 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 elm 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