05090103 CITY OF CUPERTINO ^•& -�+ ce*rE, b�=* .ter M':? x3 '32°
BUILDING DIVISION PERMIT iCONTRACTnRINFORM ATION
.a ass a5>c�;�'{�"$
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT"°.05090103
885 FESTIVAL
OWNER'S NAME: PERMIT ISSUE DATE
BOB KEYS 10570 S DEANZA BLVD 09/15/2005
NE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECT/ENGINEER: ��BL4t UILDINQ PERMIT
PLUMB - MECH
fog•.o�:o���0 0
°00 LICENSED CONTRACTOR'S DECLARATION Job Descri tion, _.vra�4��
�tit F❑ I hereby affirm that I am liarud under provisions of Chapter 9(Commencing p
W with Section of Division 3 of the Businem and Profsaiuns Code.and my license is y�},ty�7 y g
_ted inmRfnmeandII a31S REPLACE FURNACE & ADD A/C T E�ad
p�z Lkenu Cl s Lic.N
Cummcmr y rel
I� ARCHITECTS DEC re Ie �` „ %
aV I uMcmand my plans shall W uscth as public rtcnrds ]Ljlfa'3bNI# /hp\SSfJg'Ift
g0G Licensed Profcssionel
3 OWNER-BUILDER DECLARATION
I 1 hereby affirm Nat I am exempt from the Contractor's License Law for the
00 following mason.(Sccfim 703 1.5,Business and Professions Code:Any city or county
<$ which requires a permit to construct,idwr,improve,demolish,or moor any structure $7902
yZr priori its issuance,also requires the applicant for such permit to file a signed statement
< that he islicceud purmant to the provisions of NC Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yI— (commencing with Section 7")of Division 3 of the Business and Professions Cale)or
`<$ that W is exempt therefrom and the thou for On alleged exemption.Any violation of
Section]031.5 by any applicant for a Permit subjects the applicant to a civil penalty of r Occupancy Type
not more Nan five hundred dollars(8500).
❑I,as owner ofthe property,or my employees with wages is their sole compensation,
will do Newark.and the swClure is notimmmoded Or.Rered fouele(Sec.]01,1,Business Required Inspections
and Pmfesima Code:The Communist'sLicense taw dos e not apply to an owner of q p
Property who builds.,improves thereon,and h.don,such work himself.,through his
Own employes,provided that such improvements are,not intended moRered for axle If,
however.the building or improvement is sold within one year of c.mpleu.n.the owner-
builder will have the Wrden of proving that he did not Wild or improve for purpose of
sale.).
1,as owner of the properly,am exclusively contracting with licensed convectors to
consuucl Ne Project(See.9044,Business and Professions CWc:)The Contractor's U.
cense law docs not apply to an owner of progeny who Wilds or improves thereon,and
who conuacu for such projects with a contrvctm(s)licen¢d pursuant to the Commander
License Lata.
❑1.m exempt under Sec. .B&P C for this mann
Owner Dare
7371WWORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 hs ve and will maintain aCertlRma,of Consent on self-insum for Worker's Compen-
'
er,as provided for by So num 3]00 of On IaWr Code,for On pedmmans.f the
rk for which Nis permit is issued.
1 have and will maintain Worker's Compensation Inure e,as mquimd by Smum
of the labor Code,for Ne performance of Ne work for which Nis pemiir is issued.
Wr Compensation Insurance carrier and Policy number art:
me @(—V[,Lef,LJ Policy No.:
/F 9 3,:Y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section reed Trot be complemd if the pmmit is foronc hum ma dollars($100)
or less.)
1 certify Nat in the performance of the work for which this Permit is is um.I shall not
employ any person in any manner on as m become subject to tM Workers'Compensation
Law s.r California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenif¢atc of Exemption,you should
become subject w Ne Workers Compo siolim pmvisimal of the labor Code.You moat
.J O foMwith comply with such pinvuiom it or Nis permshall be domed invoked.
Z� CONSTRUCTION LENDING AGENCY
E" l hereby affirm that the,c is a convection lending agencyou the performance of
fYi ? the work for which this permit is issued(Sec.3097,Civ.C.)
IQ
0 Leml Name
Z Lender's Address
U 0 1 anify that 1 have read this application and sue,Nat the about intimation is
E' comcL 1 a&=to comply with all city and county ordinances and sue,laws relating to
0U building convection,and hereby adoinoc opmenotadveS of this city 10 enter upon me '
fJ.l above-mentioned property for inspection purposes.
(We)agree I.rive,indemnify and Inch harmless the City of Cti,miro against
nFi fa/1 Iiabititics,judgments,costs and expenses which may in any way accrue against said City
U in consequence of the gmnti ng of this Permit.
APPLICA UNDERSTAyyyyQfQQ�S AND WILL COMPLY WITH ALL NON-POINT .Issued by: Date
f fiQtlgSA ATION.$.'/�' 9/V//U Re-roofs 'K
SigntUcof AppticmVComracmf / Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant ser fuore building Occupant store or handle hammous matorial
as def ncd by the Cupertino Municipal Codd,Chapter 9.13.and the Health and Safety
S u..15532(.p , All roofs shall be inspected prior to any roofing material being installed.
❑Ye o
Will On applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hasardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distrix? /
❑secs
f
I basic mad the haxardnu.nown.la mquircmcrus umddr Chmu,16.95.f the Caliur-
miaHwlN&Saftcy Calc,Soden 25505,15533 am125534.1 understand thal Wilding
urearot cuneml have a¢nail Nal it u my ms ihililY b notify tW rap t of dte
re n his wit t W=1 pin isa.anc .CertrnCamdfwe ignature of Applicant Date
Owner or aulhorired agent qV� L D` All roof coverings to be Class "B"or better
4
4 Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
' CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: ^y.� PERMIT #
OWNER'S NAME: i PHONE # *Y 4Q-t qty
GENERAL CONTRACTOR-]p wL FAX #
I am not using any subcontractors:
Signature Date
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 e . e- 1 c`+-e- a-3Lsg
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 q bG�3
al] OF
FURNACE/AC b G
SUPERTINO PERMIT APPLICATION FORM
APN # Date: l )6s
oa
Building Address: B8s � s �Y . C u e�� t y,� Ca .
Owner's Name: in �� 5 P one :
Contractor:Ve.Xhone: �5 � License #: 7a 3 1 5CY
Contac Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Cly Plumb ❑ Mech [k'
Job Description: '? C� 44(�I C
Com
Residential mercial E]
For Residential Installations:
Attic ❑ 1" floor EV 2"d 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 ❑
C1of Project: Type of Construction: Occupancy group:
UG
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMF'URN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfin MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITTEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License 2l BUILDING