05080207 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION °;.
BUILDING ADDRESS: A PERFECT CLIMATE PERMITNO05080207
EATON21855
OWNER'S NAME: PERMIT ISSUE DATE
LINDSEY VOCKACHBRODSKY 10570 S DEANZA BLVD 08/23/2005
NF-: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECDENGINEER: BUILDING PERMITINFO
BLDGEIECf PLUMB MECH
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�0, LICENSED CONTRACTOR'S DECLARATION
m❑ I hereby affirm that I am licensed under pmvisimoa ofChaper 9(commencing Job Description
ZW with Section 7") f Division 3 of the Business and Professions Code,and my license is L. {".
<, infallmreeand 3idj� INSTALL A/C E; ' i
j i Liccnu¢kms Lic,
ED
��o ease a - of
Conuacmr t
<�5 ARCHITECTS DECLA ATI
y ad< 1 understand my plans shall W used a public records 7 20
0
Dau
u Licensed Professional
=D3 OWNER-BUILDER DECLARATION
<X I bcmhy am that affirm I am exempt Imo the Contfactar,Licenseaw Lfor the
Z o following tension.(Section 7101.5,Business and Professions Code:Any city of county
�
X m which rtyuims a permit ns construct.alcor.Improve.demnli h,m repair any structurestructureIL $5285
prior in its issuance.also requires the applicant for such permit to rile a signed statement
�0 that he is licensed pumanuo the provisions of the Contractor's Lieenu Law(Chapter 9 Sq.Ft. Floor Area Valuation
art- (commencing with Section 10(10).(Division 3 of the Business and Professions Code)or
i
that he u exempt therefrom and the basis for she alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred delta.(1500). Occupancy Type
0 1,a owner of the pmpmy,or my employees with wages as their role compensation.
will do Out work and im,tructum u not intended oroffered to,We(Sec.]Baa,Business
and Pmfessio s Cow:The Convectors License law docs we apply m an owner of Required Inspections
limpeny,who builds or improves thcfcon,and who does such work himself or through his
own employees,provided Out such impmvements art not intended or offered for We.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not Wild of improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
convect the pmjea(Sea 7004,Business and Profwions Cade:)The Convector's Li-
mount Law docs not apply m an owner of propeny who Wilds or improves thereon,and
who concocts for such projects with a contractor(s)licensed pursuant in the Contractor's
License law.
❑I amexcmptunder See ,BkPCfarthisreaon
many Data
WORKER'S COMPENSATION DECLARATION
E I hereby arum under penalty of perjury alts of the following declarations:
1 have and will maintain a Cenificee of Consent a xlf-Worsens for Worker's Compen-
sation,a provided for by Section 3]00 of the Labor Code,for On performance of the
work for which this permit is issued.
I have and will maintain Worker's Compemadon Insurance,m required by Section
7 crow labor Cotle,for Ne performance of the work for which this permit is Water.
My War Cmnwrutian Insurance carrier and policy��nnuusmber�au:
Cartier. Policy No./1i_Lt-r'-`9
CERDFICA 4OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Bus section reed not he completed if the permit is throne hundred dollars(1100)
or le,tx)
1 certify that in the performance or the work for which this permit is issued.I shall not
employ any person in any manner an a in become subjen to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenifcaa of Exemption,you should
become subject to Ne Worker's Compensation provisions of the Labor Code,you must
.,Q foMwith comply with such pmvisioa or this permit shall be dm
cecd art akcd.
Z 7) CONSTRUCTION LENDING AGENCY
PI hereby affirm that them is a construction lending agency for the performance of
a the work far which Out permit is issued(Sec.X197,Civ.C.)
U,1Q
Land fa Name
zLender's Address
U Q 1 scruffy that I have mad this application and suite that the above information is
"P coven.I agree to comply with all city and county ordinances and sate laws relating m
0 building construction.and herebyauthoris represenativies of this city to enter upon the
W .Mvoroemimied progeny far inspection puyases.
(We)agree In ave,indemnify and keep harmless the City of C.Nenimo against
f h liabilities,pri,nuna,costs and expenses which may in any way aeeme agoras said City
U Z inconsegocnccafdtegrantingofthisptnnit.
APPLICANT UNDERSTANDS/AND WILL
/,CJ0,2WJAIL NON-POINT Issued by:S4��(a Date
SOU[v lRs's-!'L CCL$ lv
Re-roofs
Signature of Applicant/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant ser future building occupant smrc orhandle haxsfdous maanal
a defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code.eetiom 35532(a)? All roofs shall be inspected prior to any roofing material being installed.
ca
If a roof is installed without first obtaining an inspection,I agree to remove
Will me applicant o.future building aceupant tau cyvipment pr devices which g
mit barardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
District? _
D Yes
Iharcmad the h.Secuas omaaria.25533mmentsunder Chapter b.95ofthe Califon-
rias not
lerviuns25titism 33and35534.I unMrsund thmiHW Wilding
dors oat currently have a mnana Nm it is my respoaiM1ility to nntity the occupant of the
qu¢mumu which must be mel Moir U,to seer a Cemneaw cnvyr. Signature of Applicant Date
'l a"CC ""__�) All roof coveriQ to be Class "B" or better
Owner ser atuhon.d agent Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
`UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
i3 Gt C°q `bl 6f-6 So 2 o 7
OWNER'S NAME: �X PHONE # - 1
GENERAL CONTRACTOR: T& (LFAX #
I am not using any subcontractors:JhOKCu �.„(apG7 ?-t1-0)/
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
16 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 __vS Z
� � ' - FURNACE/AC oS
UPEI�TINO PERMIT APPLICATION FORM
APN # Date:
Z(o
Building Address:
£a ; na 9sb i
O} er's Nam : hone #:
ontractor: one: 'License #:
"ofi 4x D r q-31 S
on act: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Electx Plumb Mech ❑
Job Description:
Residential Ix Commercial ❑
For Residential Installations-
Attic El I,, floor 2"d floor❑
Adhere to min set back re uirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning A royal Re uired ❑
Cost of Project: Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location/16Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BRENUURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn 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 BUILDING
BUSLIC Business License BUILDING- .
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