05040125 CITY OP CUPERTINO ' Ez�t
BUILDING DIVISION PI✓RMIT ,CONTRACTQR INFORMATION
BUILDING ADDRESS: PERMIT NO.
A PERFECT CLIMATE 0504.0125
OWNER'S NAME: PERMIT ISSUE DATE
NE:
SANITARY N OL NO.
ARCHITECnENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION Job DCSCriptlOn�
O p 1 Manby affirm that I am licensed under provisions of Chapter 9(commencing
p�2 with Section LMAB.r Division Sof the Busimim.nd profcssiom Code.and in,license fM c
m full force end ( t. 2 I S�
zpi LicenseCess Lica ADD A/C `
F Dep /�� Nmrenm
qq ARCHITECTS DECLARATION ❑❑r
a I understand my plans shall be,used u public records P..U5
,6^ w
Licensed Professional l
3 OWNER-BUILDER DECLARATION
aOS I hereby affirm the I am exempt from the Comrae or's License Law for the
00 following reoann.(Section 7031S.Business and Professions Code:Any city.r county
g which require a permit n,construct.abet,improve,demolish•of repair any Structure
Fib priorto its issuance,also requims the applicant for such permit to file a signed statement
xx tbar Mislicensed punuanuothe provisionsoftheCmuractorsLicense La.(Chapter 9 Sq.Ft. Floor Area Valuate
in (commencing with Section 7000)of Division 3 of be Business and Professions Cnde7 or
to Net he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant b)acivil penally of
not more than five hundred dollen(5501y. 3X811 VP1Pk`er 0 0 Occupancy Type
❑1,As owner of the property,or my employee with wages As their aide compensation,
will do the work,and the suucmm is not intended or offnW finale(Sec.]Bbd,Business
Add Professions Code:The Convector's License law docs not apply to an owner of Required Inspections
PmPeny who builds or improves thereon,end wM1n Oocs sucM1 work himself.,through his
own employoe,provided that such improvements are nm immodcd oroRered forsale.If,
however,the building or improvement is sold within one year of cnmpletion,the owner
builder will haw the burden of proving that be did not build or Improve for purpose of
sale.).
0 1,as owner or the propenY•am exclusively contracting with licensed contractors to
construct the project(Sec.7064,Business and Professions Codc:)The Contractors U.
cense Law docs not apply to an owner of property who builds or improves themon,and.
who contracts for such projects with a cmmactor(s)licensed pursuant to Na Contractors
License Law.
❑1 am exempt under Sec. .B&P C for this reason
Own" Data
WORKER'S COMPENSATION DECLARATION
1 hereby eRrm under penalty of perjury one of the following declarations:
I hsw and will maintain•Cenifiem or Continuo self-M...for Workee,Cmnpcm
Milan,es provided for by Section 3700 of the LAWT Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
371M1 of did Ube,Code,for Ne performance of the work for which this permit is issued.
My Worker' Comps sa'4n Insurance carrier end Policy number are:
Cartier. Policy No.:s�J--f1— ZZ
CERTIFICATE OF E% ION FROMWORK 5e
COMPENSAT NINSURANCE
(This section need not W completed if the Permit is for one hundred dollars I$10(B
less.)
1 cer ifv that in the perro mance of the work for which this Permit Is issued,I dull not
employ any person in any manner an as to become subject to the Workers Compensafion
Laws of California.Dam
Applicata
NOTICE TO APPLICANT:Ir,alter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of tho lobo Code,you must
.JO forthwith comply with such provitinm or this permitshall M doomed rewwd.
Z � CONSTRUCTION LENDING AGENCY r
P: I hereby affirm that there is a construction lending agency for the performance of
a Ne work for which this permit Is issued(See YN7.Civ.C.)
W Q Lcinces Name
z Londe,.Address
U C) I carry Nn I have read this.p,licsti.n and sum the the.1sove informuiun is
W F correct.l agree to comply with all city and county ordinances and state laws rclaingto
0 building convection,and hereby aath.riac representatives of this city to caner upon the
W ehpvomemioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
F" N liabilitieajudgmems,costs and expenses which may in any way accme against said City
U Z in comepience orlhe granting.(,his permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY
/JWITH ALL NON-POINT Issued by: Date
SOURCER UIL(.IVLk:t� I�'"`^-'�
Re-roofs 6
Signature of Applicant/Contnclor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant OF future building occupant store or handle haodous material
As di fined by the Cuper inn Municipal Code.Chapter 9.12,and the Health and Safety
,diiLCodc.Sccties 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the epplicam o furore building necupam use cyulpmcm or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxafdom air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
isvict7 •` / `
❑yes
I have mad the hsxaNnus materials requirements under Chapter 695 of the Califor-
nia Health&SdclyCode,Seeuum 25515.25533 and 25534.1 understand dml if the Wilding
docs Out currently hats B tenant,mat it u my respomihility to noul'y too occupant of the
requi mcnuwMchmuslhmnprproissuvt nncroficamof c.Parley. Signature of Applicant Date
owner.,autho"xcde'rad 0./ DD All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: -2-111,6 ZLl-{ W PL, . PERMIT # �J 0> Z-j
ALppm,rl-D OWNER'S N VIS PHONE # —V
GENERAL CONTRACTOR: Mk- FAX #
I am not using any subcontractors: P�IIGl�1 Cfti %V ��- -tel b
Signature VDate
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
�j Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper —`
Paving -
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
/y Tile
4-a1-oS
Owner/Contracto ignature Date
OF
CITYFURNACE/AC
ICRY OF
UPEkTINO PERMIT APPLICATION FORM
APN #
Building Address: -
21-11 S L .
Owner's Name: Phone #:
Contractor: Phone: ticense #:
�r :C-I �lLvnat� q&1 @0 - s - a3 s`2
Contact: Phone: Cupertino Business License #:
V- rM c�I h I -SIS"4S ZI Liq
.Building Permit Info: .
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:Aad
Residential If� _- .__ Commercial ❑ _
For Residential Installations: ~�
ttic ❑ 1st floor ❑ Zed floor❑ - -- -
dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation. El. - •- -
New installation Planning Approval Required ❑ - -
Cost of Project: $Lf, 22-; Type of Construction: — Occupancy group:
460 At Ci
Strapped ❑ On Platform ❑ Bonded ❑ - Sq.Ft. Floor Area:
New Location ❑ Re lacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN 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
Am 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 Licens BUILDING
1. �7