03080061 CrrY OF CUPERTINo
BUILDING DIVISION PERMIT CONTRACTOR INFQRMATIQN. '
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT N003080061
21085 FREEDOM
ER'S NAME: 10570 S DEANZiA BLVD PERMIT ISSUE DATE
TAEGE MARIAN L 08/14/2003
NE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECTIENGINE[R:
BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
?op LICENSED CONTRACTOR'S DECLARATION Jo .a1�y ��
U r 1 hereby affirm that 1 em licensed under provisions of Chapter 9(commencing F}kf
?Zw with Sc xer,aI�(lU)nf Division Jof me Buxincv an�ofczWnx CodP.antl my license ix
a-gym inlullC, and Cl O?i// S((�/� REPLACE FURNACE
ton 2 License
CI Lic.N JAN 2 8 2004
�F-p Datc Contractor
££ AR HITEC'5 DECLAR o }�N�
C 1 undcmta d my plans sM1all W iced as puNic r cnrUs A qy p p�p�p��ap/���
Et; Eiecamd Pmfcsslonal
OWNER-BUILDER DECLARATION
I hereby e(firm that I am exempt from the Contractor's Liccnsc Lew for the
p O following mmmr.(Section]1131.5.Business and Prnfcssions Code:Any divot county
e m 4 which requires a perms m construct,Ober,improve,demolish,or repair any xbucture $2718
O—,, poor it)its issuance.also requires the applicantferrsueM1 permitto file asigned statement
'cs< that he is licensed purxnlm the prvisiortsof NC Contractors License Law Sq.Ft. Floor Area Valuation
ro
e,p (commencing with Section)0)0)nfDivi on3oftheBusinessandProfusionsCoul0or 32653030 . 00
OFF that 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 to a civil penalty of ApN Number Occupancy Type
not mart Nan five hundred dollars(S!KKE.
❑1,az owner error property.or my cmployces with wages as their sole compensation,
will do the work,and the strucwm is not intended or offered for sale(See.]04,1,Business — LN
and Profcssianx Code:The Contractors License Law does not apply to an owner of 3 03 - ROUGH eons
property who builds or improves thereon.and who does such work himself ter thmugh his
n employees.provided that Such improvements are not intended or offered for aske.R. 304 — ROUGH ELECTRICAL
however.the building or improvement is sold within one year of completion.the owner.
builder will have the Wmen of proving that he did not Wild or improve ler pumoee or 505 — FINAL ELECTRICAL
sale.). 507 — FINAL PLUMBING
E] I.as owner of the property,am exclusively contracting with licensed emomemrs to 508 — FINAL MECHANI CAL
Construct the project(Sec.]044,Business and Profusions Code:)The Contractors Li.
thoraxeshc
cents,Law does not apply to an owner of property who Wilda or thoruvtmon.and,
who contracts for such projects with a eontraetepursuant r(s)licensed pursuano me Conoactor's
License
Law.
❑ I am exempt under Sec, .B&P C for this reason
Data
WORKER'S COMPENSATION DECLARATION
I hereby allitm under penalty of perjury one of the following declarations:
I has and will maintai n a Certificate of Consent to sel f-insumfor Worker's Cum pen-
sation, a ovided for by Section 37M of the Labor Code,for me pcomaramn,of the
war r which this permit is issued.
1 have and will maintain Workers Compensation Insurance,ax required by Section
3 of thc labor Code,for me Wrimorana of the work for which this permit is issued.
My orkeis Cnmpencrom Insurance carrierand Policy Burn is :
Canicv Policy No.:
ICA EO E PTION FROM WORKERS'
COMPENS T ON INSURANCE
(This section need not W completed if the NOrr is for one hundred dollars(SIM)
m Itss)
1 certify that in the performance of she work for which this permit is issued.1 shall not
employ any person in any manner set as in hacomc subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of IN,Labor Code.you must
., ,Z formwith comply with such provisions or this permit shall W deemed evoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that mere is a construction lending agency lot the Performance of
:4 me work fur which this permit is issued(Sec.309].Civ.C.)
!y Q Undeis Name
a Under's Address
V Q 1 certify that 1 have read this application and sure that the above information is
0 U toilet 1 agree Construction.
nnum comply with all city and county ordinances and Cott laws relating upt to /h
C.) above mentioned mart hcabyanthom pne rposes.nulivesofthiscity to enter upon the
r W
above mentioned property for impecd nn purposes.
,r (We)Am
nd n ccp harm is the City of Cupcnst against
N liabilities,juddexpenuaw ich yen way accrue against aid city
C) or
z of DS A Dr 1 P H LL NON-POINT Issued by: Date I�
Re-roofs
Sign fp canvcantrac e
HALARD US MATERIALS DISCLOSU Type of Roof
W;II capplicam or futon Wu"m gueeupam atom or hon Ic haruduus material
az defined by me Cupertino Municipal We.Chapter 9.1i.and the Health and Safety
e.Semon 25532(a>? - All roofs shall be inspected prior to any roofing material being installed.
Vcs
Will mea applicant or re Int ant use equipment or devices which If a roof is installed without first-obtaining an inspection, I agree to remove
pp u Eby theit
.it haardous air conumin ts az toed by the Bay Arca Air Quality Management all new materials for inspection.
District?
Vcs
Ihave read the here as eta itements under Chapter 6.95 of the Calirm.
Dia Healed&SafetyC 25N15.2 3 d 155J4.Iundcraccomnifmc Wading
Jlss not cumcntly ha eta mat it u mihilit Badly the axupant of the
requirements which tW epoor iseo ce f Ocae or parer Signature of Applicant Date
owner or sub zed agent D All roof coverings to be Class "B" or better
CITY OF CUPERTINO
_.
' PERMIT APPLICATION FORM
APN# 55 Cl5b
Date: I �3
Building Address:
Owner's N e: Phone #:
CartCA f-CA-e-, - KS
Contractor: License #
a3 ids
Contac Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description: "LC-<-Q
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd 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
Cos�fPlojec: S-1 Typ fConstruction: Occpncygrou: ,L -
1n fd(t.0
Strapped El On Platform Ll Bonded El Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bld k Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING