03100085 CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT 4CONTRACTOR INFORMATION
BUILDING ADDRESS: A PERFECT CLIMATE , PERMIT NO 03100085
OWNF.R'SNAME: 10570 S DEANZA BLVD PERMTISSUEDATE
JNE: (408) 861-9545 SANITARY N0. CONTROL NO.
ARCHITECrlENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Too LICENSED CONTRACTOR'S DECLARATION
FF I hereby affirm that 1 am licensed under provisions of Chapter'')JInein, lob SCfI�IrhO��n®®pp ppp
IQ.Zty with Senium Tl of 3ofthc Business .a/d/avlicensn is 1N/ LEO
in full for. an f I UU `>0
uansd tie.. ADD A/C
o Dam Lic. ter
�� A IIIETgDEeI. NOV 5 2003
I understand my It shall be used as p tic nNs
'au
.oG Licensed Professional p�U'�aD�.YM
OWNER-BUILDER DECLARATION
't2 a 7 1 hereby air..mm I am exempt fru.the Comraam's License Law for the 1IYYFFrr//[[
0 o following reason.(Section 7031.5.Business and Professions Code:Any city or county
i$ which m9Uires a permit to construct,alcor,improve,demolish,or mbar any structure
a�'^ prior 1,its issuance.also requires the applicant Lar such permit.lite a signedsutcmcnt
that he is licensed puammw the provisions Of Contractor's License law(Chmmr 9 Sq. Ft. Floor Area Valuation
i='O (commencing wi th Section 71)0)of Division 3 Of B usinees and Profeasinas Code)or
Nat he is exempt therefrom and the basis for Use alleged exemption.Any violation of
Section?031.5 by any applicant for.permit subjects the app]iC.L I.a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(35(n). P Y YP
D 1,as owner of the property,Or my employees with wags as their sole compensation, TT�Jp�p�
will do the work.and the swmumis not intended or offered for sale(So,.]D14.Bulinus 301 — ROUGH � tl1r2(Y lI9�CCIIODS
and Professions Code:The ComracoWs Licavu law docs not apply to an owner or P_
proptnywhobuildricomprovcsthereon,andwhod«sa«hwarkhimulformrougbhis 303 - ROUGH M CHANICAL
own employ=,provided that such improvements are not intended or offered for sale.If. 304 — ROUGH ELECTRICAL
however,the building or improvement is writ within one year or completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of 505 — FINAL ELECTRICAL
D 1.as owner of the property,am exclusively convecting with licensed eommicuma to 507 — FINAL PLUMBING
Consumer the project(See,7044,Business and Pwrcasions Code:)The Comeacwr's Li- 508 — FINAL MECHANICAL
cuue law docs not apply to an owner of property who Wilds or improves demon,and
who contacts for such projects with a court acrods)licensed pursuanno the Contractor s
License Law.
D 1 em vempl under Sec. .B At P C for this maim,
Owner Dae
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pcnahy of perjury o«of the f diens ng deelaraiom:
1 have and will maintain a Certificate of Consent to sel6lname for Worker's Compere
lotion,as provided for by Section 3700 of the Labor Code,for the performance of the
ork f which Nis permit is issued.
have and will maintain Worker's Compnuadon Laurance,as requited by Section
00 of the labor Code,for the performance of Ne work for which this permit is issued.
Worker's n peniaunnc artier and Policy
Carrico ns olicy Nu.: f{JfC
CERTIPI ATEOFEJE ION FROM WOR E S'
COMPENSAT NINSURANCE
mars section need not nth completed ifuW permit is(mune hundred dollars 15101)
,r Mss.)
I comfy that in the perhsrmance of the work for which this permit is issued,I shall nut
employ any person in any manner so as m become subject o the WorkersCompensation
Laws of Califmnia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject w the Workel's Com«msauoa provisions of Inc Labor Code.you must
z forthwith comply with such provisions or this permit shall W deemed invoked.
ZOCONSTRUCTION LENDING AGENCY
I hereby affirm that Inert is a construction lending agency for the performance of
L) m IW work for which this permit is issued(Sec.00)7.Civ.C.)
L)Q Lndr's Add
L
Lender's css
jz
Q 1 certify that I have wad thisapplication
and County
sold sale that the samestrivel wsorelating it
L F building I agree w comply with all city and county umimanms and same lows relating to
e
V adowe-oremmlding om!en,and hereby inspection purposes. of this city no corer upon Inc
r a ahmvc-(We) cd to shlysive for inspccriond keep ha.
(We)egme to cove,indemnify and keep nay In icn, City or Cupertino against /v
i,iZbull inconsequedeofthecosaan dt' swhicn may in an crud against said City r/
Z Aconsegmnce ofthegrmtin t permit.
^ APPLICANT UNDER / z
NOS NO PLY W HALL NON- OIN Issued by: Date
SOURCEREGU N5. e
Re-roofs
mor Appfiant/c racmr am
RDOUS MATERIALS ISCLOSURE Type of Roof
Will thea camorfrume build, ..up " me of handle hasarduus material
as defined by me Cupeninn Municipa ode.Chapter 9.12,and the Health and Safety
Code,setdnn zss3z(a)? All roofs shall be inspected nor[o an roofing material beim installed.
Yes
p P P Y g g
teal and a Leann writ oil n «m am and a If a roof is installed without first obtaining an inspection,I agree to remove
PP g p quipmcm or Mvices which
it naearMus airmnmminan ses mod by the Bay Arca Air Quality Management all new materials for inspection.
n?
Dyes N
I have read me haurdnu nmrials requiwments under Chapter 6.45 of the Califor.
Iia Health&Safety CCM.Sec- 505.25533md25534A undmat;free Wilding
does not cumad,have a n my rtsparui notify drt r mupanl of e
requirements which mus Iprior ter sew«o Beim Cl ad Signature of Applicant Date
ow, n ,;. agd,I Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO p D�
d' FURNACE/AC 3
OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: ) 1 gy CGV 2�1]Y 1� S p�-,nn 0--
Owner's Name: - fe.(�,^ U� Phone#:�S _D< /0
��
Contractor: y�jC� G l hone: 1408 q(.P,_C?5 Z/ License�a 3 )S, ')
Contact: Phone: Cupertino Business License#:
1
Building Permit Info
Bld ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descri ion: AOC
Residenti Commercial ❑
For Residential Installations:
Attic ❑ I"floor ❑ 2nd floor❑
• Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structuralEl calcs)
Structural Calculations required for new installation El
New installation Planning Approval Required ❑
Vr
Cost Prgj�t- Type of, onstruc Occupancygroup:
Strapped ❑ On Platform ❑ Bonded Sq.Ft. oor Area:
New Location ❑ Replacement ❑
Qty. if
A l� a le 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 c MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMrIFEE 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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