04090251 CITY OF CUPERTINO
BUILDING DIVISION PERMIT s.CONTRACTORI, Nk'ORMATION:
BUILDING ADDRESS: PERMIT NO.
A PERFECT CLIMATE 04090251
OW NER'S NAME: PERMIT L4UE DATE
ONE: SANITARY 24T C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo0
LICENSED CONTRACIOR'SDECLARATION
JobDescriptio�l /�
ydUC I am7 offirmhot lamlicencedunderprovitiomofCbaaer9(commencing N!"�L,
U wED
ird csion ndtficfDivision 3a(Ihe Business anQRrafessiuna Codc.and my license is 'VY
a ,an in ren and errec,.^ v / REPLACE FURNACE
z License I Lie.d
'-p Dam Contmcwr SEP ��
CHIECTS DEC ON J 2001.
5y a 1 understand m no shall he used as public mmmrds T
Di
301 LiccmcJProrcmional BUILDING '
sad OWNER-BUILDER DECLARATION
1 hereby affirm Lha 11. exempt from Ne COmnctCo License Law for the
Oo which betursan,(Srmit to In LS,Buaiter andunpu Professions Co dc:Any city scounty
m� which esquires a permit so enrutmct,alter,improve,demoliah,or repair any structure
y prior to its issuance,also mquime the applicant for such permit to Tile a signed summon,
t�< Nat he is licensed pursuantto the provisions of me Connector's Umose Law(Chapter9 Sq. Ft. Floor Area Valuat on
at n (commencing with Scion 7")of Division 3 of the Business and Profession Chats)or
y that he u exempt dominant and the basis for Ne alleged exemption.Any violation of
Schon 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3 2 .*-T*9l0 0 Occupancy Type
not more Nan five hundred cle las($500).
I.asawn,k.and
properly,m my wployeeraimvnges rtheirsole compensation,
will do I' mework-endue he Comisntes LtdW m mfilhool Law
.1 pplytOaa,Buuws Required Inspections
and Profession Cade:The Canua,on,Liana secs dose rot apply lf an owner of q P
propertywhab provided test ach improvements
andwho doemn workhimulfmdumugh his
own a ere due buiprovided ma each improvemcm are not,U Ofororo@md for mle If,
however,me buildingha improvement Issold within one yea of completion,repose of
builder will have Ih burden of proving that he did not build or improve for purpose of
sake).
❑I.as owner of do promny.am melusively contracting wit liccrued contractors to
construct he po ject(Sec.7814.Business and Professions Code*The Contsanofs U-
cease Law does not apply m an owner of property who bands or improves Leman,and
Who contracts for such pmjecu win a mmoactor(s)licensed Panama,m the Conuctofs
License law.
I an exempt under Sae. ,B&PC fm this numb
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby&Run under penalty of perjury one of the following decuraions:
I have and will maintain a Cenificam of Consent to self-insure for Worker's Compere
7C37]'00
ian,m provided for by Section 3]00 of the Labor Code.for the l edmmase of me
rk for which this permit is issued.
I have and will Tasmain Wwkcr's Compensation Insurance,m required by Section
or me Labor Code.for de pcmfa romec of the wort for which this permit uhoundy Worke 'em"on lnumnm earn,and Policy number art: �/C ,: YYI _ Na.: i4Nqu3SG
ATIFICATEOF EM NFROM WORKERS'
COMPEN NINSURANCE
Croix action need nothecomplesed if the permit is formic hundred do lam($1001
ar lcea.)
I certify that in to performance of the work fm which this Permit is broad,I shall not
employ any person in any manner a as W become mije,W me Wmiams'Comparomma
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of EacmPtian,you mould
become subject W the Worker's Compcnmdon provisions of me labor Code,you must
{Z, forthwith comply with such provisions or this permit shall be deemed remked.
Z O CONSTRUCTION LENDING AGENCY
[-.V) Ihemby N^n has there is a construction lending agency for me Performance of
a> to work for which mus permit is issued(Sec.3097,Civ.C.)
lP1Q Le tic 3 Name
lender's Address
V 0 1 certify that 1 have read this application and sum that the above infmmatiun is
"r. cont,.1 ague to comply with al city and court,ordinances and$use laws ml W ng W
V building construction.10ae.indc aifyandupresemauve$of this Ofymenmrupon the
> Ul above-mcmioned Property for inpection purposes
CL
(WO)sju agree to cove,indemnify and lump,ha in m me City of Cupenst s against
fM rA liabilities.judgmenu.cosu and eapcnxa which may in any way eceme against said City
U incomequcnceofthsgrantingofduty Nnolt. Date
^^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOU
RC ULA IONS.
Re-roofs
Sig t ca Ay ¢ cmdracmr D Type ofRoof
HAZARDOUS MATERIALS""LOS'
Will the epplimm.,future buildingoocupanumm or hart aI as mucrud
defined by the Cupertino Municipal Code,Chapter 9.12„a the Health and Saay
Code.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
0y. o
Will the applicant future building Occupant nate equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardous aur comm tams m dcfined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I havemal the h.ardousmamnials oquiremenumet,Chapar6.95ofmMCalifor-
meHcaldu&Safety Cmk,Stmons 25505.25533 md25514,l understand thairme Wilding
docs not cumnab hoc a mnan4 tee,it h my rcaponsihilitY W rodlY due occupant of Uma
mquirtmc lwhi d apriarWiyy cerdfcn,of y�_, n Signature of Applicant Date
A (,Y�' All roof coverings to be Class"B"or better
Own rror auth;h nd agent � bam
Community Development
' 10300 Torre Avenue
AS
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: ` .5 PERMIT #
6 1670102CCk?
OWNER'S NAME: l C PHONE # \
GENERAL CONTRACTOR:
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 Z,
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T' e
wrier/Contractor Signature ' i Date
CITY OF CUPERTINO 7 a 2 _`
n -
V, JR i�'r�.CE/_'� C v l
UPERTINO PERMIT APPLICATION FORM
APN # _f5
_02 Date:
Zlq
v
Building Address: ,2i l f,50
Owner's Name: l Pho #:
fQ Vgce ne08^-25z-c1
Contractor: /I I n^ Phone:- n L„' License #: -7Z3
Contact: ( V"1 Phone:l (� Cupertino Business License #:
Building Permit nfo:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑/ Commercial ❑
For Residential Installations:
Attic ❑ ls` floor ❑ 2'd floor❑
Adhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural cales) ❑
Structural Calculations required for new installation ❑
New, installation PlanningApproval Re uired ❑
Cost of Project: Type of Construction: ' /, !�� Occupancy group:
Strapped ❑ On Platfonm ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A li if e 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
J BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
Ah PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License J RUILDFNG
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