04100154 CITY C F CUP ERTINO "` "
BUILDING DIVISION PERMIT CONTRACTWA ' ORMATION• -
BUILDING ADDRESS: PERMIT NO.
A PERFECT CLIMATE 04100154
OWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY OL NO.
ARCHITECT/ NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo0 LICENSED CONTRACOWS DECLARATION Job De$CrIpUOD
ZC I bartby arfn slur I am licensed under provisions of Chapter 9(exo menein6
<ou with Section 7") !Division 3 of Ne Businevutd Profrssions Codc.and my license is t��
n„ mrunmre and Ale (-2d 2 (cj REPLACE FRUNACE 11{lam HALE®
z z to U 1 Lic.N
a F O Da¢ Cant_
FF 7W ARCHITECTS DELLA ATIO
I undeuund my plans shall be used as public records
;�t; Liaised PmfceVonal
NOV 4 2004
3 OWNER-BUILDER DECLARATION
'i S I hereby M.Na.1 am exempt from Nc Conwnafs Lkense Law for to
DO following mason.(Section 1031.5,Business and Pmfessiuns Code:Any city or county
$ which requires a Permit.construe.,alcor,improve,demolish,nr.,.it any structure
prior in its issuance.also mquirm rho applicam for such penis.file a signed summon.
tsiBOOM ialicc.dPursuant.thep.visimuoftmCmu corauccn.Low(CMpmr9 Sq.Ft.Floor Area uato
Wh$ (commencing with Section 701301 of Division 3O the,Business and P.fessiom Code)or
.. ihn Or is exempt Ne.from and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 q �I �erO 0 Occupancy Type
out more Nan five hundred doll..($5007.
O 1,as owner of Ne property.or my employees with wages m Neo sole eompew.lon,
will do Ncwork endo: ahemraoati Lt. oraw does
We. ewer!
mad Profusions Code:The Comecon Ld who Law dors or apply lf an owner is Required Inspections
Property who builds or imp.va Hereon,and who does such work himself ed..ugh his
own employe..provided that vemimp.wmmts are nos record opted ed forone O e.If.
builder .Nebuildinguimprowmensiscoldwithinane year of mprowfn,one Owner.
builder will have the bunion of proving Na.he did not build or improve for puryose of
sale.).
❑1.as.,of the propeny..m exchnowly contracting with licensed conuac.0 so
construct the projms(Sec.706x.Busines sand Pmfcssmos Code:)The Conuac.ri Li.
me Law does not apply to an owner of property who builds or improves memon,and
who contracts for such projects with a commentr(s)licensed pursuant to me Conuac.oYa
License Law.
❑1 un exempt under Sec .B h P C for Nis mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby ff..under penehy of perjury..of thn following decimations: -
1 haw and will maintain a Cenificons of Consent to sel6insure far Worlds Compen-
sation.as provided for by Section 3700 of But Later Code,for the perronana of me
work for which this permit is issued.
I have and will maintain Wortefs compensation Imuran,as required by Section
110D.1'on,Labor Code,for Ne pedonamc of Ne work for which this permit is issued.
My WorkcfsCompo .tion psumndclalnicr and Policy numb'^
Cartier: — 1 f lN� Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed Brhe penf is for one hundred dollars($ID()
or less.)
I certify that in the performance of the work for which this permt is issued,I shall not
employ any person in any mannerso as.become subject to dm WOmxW Compo.adim
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Ceniftea.of Exemption,you should
become subject.Ne Worker's Compemation provisions of One Later Code.you most
.JZ forthwith comply with such provisions or this Permit shall be deemed revoked.
O
CONSTRUCTION LENDING AGENCY
[•- Ihereby affirm that Nem is.comt.cdcut lending agency for do pcol nenuf
"1
ft work for which this permit Is issued(See.3097,Civ.C.)
aA Lsndcfs Nurse
.7 z Lenders Add.
U Q 1 comfy that I hoc read this application and some thm the show information is
Uy F correct.I agree to comply with all city and county ordinances and sum laws miming.o
0U building convection,and hereby molon7c mpcoommim of this city to enter upon dm
show mentioned pup rry for inspection purposes.
(We)agree to ss..indemnify and keep hmmlem the City Of Cupcnin t against
F" faA Liabilities jvdgmemu,costs ande.pemu which may in any way accrue agamat said City V
U in emasqucnee of the granting of this Permit. o
APPLICANT UNDERSTANDS AND WILL COMP�ALL NON-POINT Issued by:%�k Date
SOUR GUL TI NS.
Re-roofs
Sign oma m onuactor au
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store Or handle havardous material
as defined by the Cupertino Municipal Cade.Chapter 9.11,and dm Heil.h and Sarety
Code.SpcYex 15531(.)? V/JNo All roofs shall be inspected prior to any roofing material being installed.
Will mea .can.or ILlurc building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.it M1armdnus a i contaminanm as defined n ft Area rt Quotid Management r r r a all new materials for inspection.
DistriaT /,
1 haw real the lusardous ma.rials reyuiremcnts under ChaPmr b.Y3 of the Glifnry
nus troth&Safety Cade,secvomhat 1, J5533au11s536.lu,notify
NuifNe building
Jou not currently haw•renew that it u rmpomibilitY.mti(Y da acupanl n(Jre
m men w - u merpdo0. 'i r Ce.ree.afocmn n Q Signature of Applicant Date
warWaatharivcd agent Da All roof coverings to be Class "B"or better
Community Development
Fie!atHvo 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: dQ rC C PERMIT # lE—)
OWNER'S NAME: ,Lj IPHONE #
GENERAL CONTRACTOR: L6LFAX #
I am not using any subcontractors: � b
Signature Da
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
bwner/ Signature Dae
-� CITY OF CUPERTINO
(/ TvLJRoS�F
UPEkTINO PERMIT APPLICATION FORM
APN # 2i ' r7 Date: Zl v
Building Address: //��/,((oqf/ <g-
0�
ll
Owner's Name: � � Phone
Contractor: Phone: �a / ,n� License #(•�
Contact: Phone: � S Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential' Commercial ❑
For Residential Installations:
Attic ❑ ls` floor ❑ 2°d floor ❑
Adhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: ! Oy g
ccupancrou
V
Strapped ❑ On Platform Bonded ❑ Sq.Ft. Floor
New Location ❑ Re lacement ❑
Qty. if
A 6 e Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
1 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
13PERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License Z BUILDING