06010040 CITY OF CUPERTINO b✓,:arx^ 's a "i "TMS -` ` ii .�'#w.r.f3e ""
BUILDING DIVISION pEjT xCANTRtfG"'CAIi I1V�U'L2MAfICI
..Ra,fg. t?kr wgra 5 „ rz; 7
BUILDING ADDRESS: -A PERFECT CLIMATE PERMITND.06O1004O
OWNER'S NAME: FERMITLSSUBDATE
DONALD GAREBATZ 10570 S DEANZA BLVD 01/09/2006
NE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECDENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�oo LICENSED CONTRACmR'S DECLARATION y Job]z�§CII���OIg�fn
1Wrcbyaffirmmm lam licensed Bu under pit ProfssofCWpter9(commencing lfOl�lk%ltp �;{�. �®
with SCctioo]IXNq ofDivivan Sof the BusinrsA and Pm(cWom Code.mdm Ikemeis
n infuuto=and e REPLACE FURNACE
��2 Lkcntt C Lk.N
� Dau Conuacmr
As shill rose
DECLARATION .�F1ry �� 2UU6
�y I understand my plant shill bo rend u public records, L
5 c� Licensed Professional (�(t
3 OWNER-BUILDER 703L5,Bush.DECLARATION I'Td'I �I�� us A �r�
+� I hereby
alum
that I am exempt fount the Contrai License Law for the Ipy^V�`}(1 ggl�t/p� i �aT�\TVlppl}kQ{``��.JV.J,
O O following rtnson.(Section]1131:3,Bursars and Profession Cade:My Illy nr county
$�i which rec uirn a perm,to continual,slur,improve,demoltah,or mirair any a.14m 3828
prior in tit,iuuaae,also requires the applicant far such permit to Ole asigned suumem
FF < that he Isllanudpunuantin the previsions;ofthe ContrumriLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
Y � (commencing with Section 7000)of Division 3 of the Bmincssanl Professions Code)or
�.,
that he isaaempt themtom and the hissta for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject,the applicant to a civil penalty of
R99K,= Occupancy Type
not mom Nen Ove hundred dollen(SSOD).
❑I,As ormarofthe property,ormyemployces with wages uNeirsolewmpenudon,
will do the work and Utestrumme knot intended mortared for We(See.7044,Business
and Pm(esslon,Code:The Commaim's Liane Low don ant apply m an owner of Required Inspections
properly who WIIds or Wmprovn therearri whodamAuehwork himself mlh augh his
own employers,providnd Wuuch impsowmemu art notimmolod molfued for Asia.If.
bowever.Uu building or improvement is sold within one year of completion,the names.
Wilder will new the burden of proving Uut he did ant Wild in improve fm purpose of
ick.).
❑1,u away of the pmpany.Am ea eleAwly contracting with Foennd conusomn in
construct the project(See.70",Bminess and Profession Cade:)The Conuacrar's W-
anes law docs not apply in an owner of property who Wilde or Improves Uurcon,end
who contacts for such pmjecu with a conurmim(s)llamed pu sinal to the Conmetors
License law.
O l oro exempt under Sea. ,B&PC for this uason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I herchy efOrm under penalty of perjury arc of the following declaration: -
1hon endwlll meinuin•CeNOamof Conantmse1f.inumfm Wob sCompen-
on,As provided for by Section 3700 of the labor Code.for the performance of the
work for which Nis permit is tissued.
,,Q�,,FFnew and will maintain Work re's Campewdon insurance.u required by Section
Y700af the labor Code,For ma perrarmana clubs wak fawhich Nis permit u Woad.
My Warker's Compensation Insunrta aria end Policy n�u(m!b[err ic�e(����s/�
Greer. Policy No.: 194-0 1 _
C IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thk section becd mnoccompleued if du peonit 6 Foran.hundred doll.(SIM)
or less.)
I cenify mot in the performance of the work for which rob permit Is Issued.l shell not
employ any person In any mannerm as At become subject to du Worker,'Comanntion
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ce ti0cam of Exemption.you should
become subject m the Worker's Compensation provldona of the IJbor Code,you muss
.JO ford ith comply with such provision m this peoni,Nail tic domed tcwked.
CONSTRUCTION LENDING AGENCY
I hereby afron Nat dun it. automation loading sgcny for the perfmmsac of
a% the.,it for which this permit k second(Ser.3097,Civ.C.)
Cy Q lands,Name
z Lenders Address .
U Q 1 ttnlfy that 1 have sad thisApplication
and county
and sou mat the above information to
D.F cannot.l Agra m amply wire all City and seamy omlnaaor and Nb lawn Waling to
0 C.) above-mentioned
pigmy forcbyaumonmmoses. Lives of thisaitymcnurupon me
[27 above-(Wi)agre to property forimpemm�pkpmes.
(Wc)gene to an.indemnify and keep hannku the City of cupenit against
vy y ilabilidez,jincoratchiudeofthecosuwd es pens es which may In any way scenic against rid City
t) A APPLICANT
of the{Sling of this peonll.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ISSUed by: Date ,
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS St{nuurt ofApplicaactm Dau
MApa DISCLOSURE
Type of Roof
WIII Applicant a( un Wading occupant mo orlundk h amaterial
As Oe0erd by the Cupertino Municipal Code.CWpar 9.12.and the Health and
Safety -
cada,ce'm 255320)7 t o All roofs shall be inspected prior to any roofing material being installed.
Win the applicant of future building occupant use equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
It honrdnus air conuminanis ss fined by m.Bay AS Air Quality Management all new materials for inspection.
;rule,?
❑Yes o
I have tad the haraod umamdalm requirements under Chapur6.95 ofine Califor- / /�
nia Health&Safcly Codd.Sections25505,25533 And 25334.1 understood thnifdte Wilding b /I 6/ /
dam not curer, have a unset that It ism meponthilBy An noul'Y Ou encupanl of the TAI L _!9 10
rt�okgnu, hmust W^it r miss Ana ole CeNOau of l)crymngY. Signature of Applicant Date
�C)Ro `. t(-(f/7f, All roof coverings to be Class"B"or better
Owner orauthodmde cat Dam
Community Development
+ " 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #ag o
00 3 4 6 grecs - T
OWNER'S NAME: PHONE # "(4 7
GENERAL CONTRACTOR. 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
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
FURNACE/AC
CUPEfi;TINO PERMIT APPLICATION FORM
APN# Date:
2 6, / 6 0 6
Building Address
IOD-53
� �cQ
Ow er's Na e: nn Phone 6
2,Z a Dovta-1 CQ
Contracto!Re,
• o License #: 1
'der er, C vttaf e 7o`3 ISS'
Contac Cupertino B siness License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mee fLJ/
Job Descriptio
V h.4c
Residential Commercial ❑
For Residential Insta tions:
Attic ❑ I" floor 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 Plannin A royal Re uired ❑
st of Project: ype of Construct' n: Occupancy g 7oup:
3� o b
Strapped ❑ On Platform ❑ Bonded L Sq.Ft. Floor Area:
New Location ❑ Replacement Ldp
Qty. if
A licable Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm-----7 MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
/ EPERMITFEE Elec Pen-nit Issua—nce----7 ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
• BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Lice BUILDING