03100086 rcITY OE CUPERTINoBUILDING DIVISION PERMIT CONTI2AC,1OIZiINFORMATION, zo-4,LDING ADDRESS: A PERFECT CLIMATE PERMIT NO.03100086
OWNER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
,NE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!O0 LICENSED CONTRACTOR'S DECLARATION
m C I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Descrip(tQ01
with Scaiun] N))Oo f D' inyL rNC Businessan a•ai Co .aaM ylicen is F 1YALED
in
Aandcf c V (l ADD ASC
;12 Z License Lic.a
�L,o Dam
Contractor
and NOV Q b
2003
rs mAs W.
Y
shall he used as public menrds
>ou
tow Licensed Professional
I OWNER-BUILDER DECLARATION BUILDING
)e Y 1 hcrchy affirm that 1 am exempt from the Contrator's License Law for the
:0 O following neaxon.(Section]031.5.Business and Pmfavions Cole:Any city or county
which requires a permit to construaL alio,,improve demolish,or repair SAY strvemrc
prior to its iuuanm.also requires the applicant for such permiun file asigned statement
tt
350
< that he isliecncedpursuanothe, m
provisioortheContractor''sLicensclsw(Charter9 Sq. FL Floor Area Valuauon
-$2 (commencing with Section 7")of Division 3 of the Business and Professions Code)or
—
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 35719100 . 00
Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the pmpcny.or my employees with wages u their sale compensation. y� Ti Ta4T�T
will do the work,and the suucturc is not intended or offered for sale(Sec. Business — ROUGH It tllred'Yf S�Bctlons
and Psofauimu Cade:The Contractual,License low Cars not apply w an owner of 303 - ROUGH M CHAN I CAL
property who builds or improses thereon,and who doessuch work himself or through his
awn employees,provided that such impmwments we not immnded or offered forsale.B, 304 - ROUGH ELECTRICAL
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of Proving that he did not build or impmve for purpose of 505 - FINAL ELECTRICAL
4')' 507 - FINAL PLUMBING
0,1.as owner of the property,am aoluslvCIY contmcdng with licensed contractors to 508 - FINAL MECHANICAL
Construct the project(Sec.]044,Business and professions Code:)Tho,Conoactor's Li-
Rose Law does At apply on an Owoer of property who builds or impums Demon,and
wh dmmctsfor such pmjccm with a contranor(s)licensed pursuant to the Conm¢toia
se Law.
asn ea m tun c Sc .B& rwi -LT
.All Dole
ORKE P SA]ON ECLARATION
I hereby affirm under penalty of pudorl, n of the following declarations:
1 have and will maintain a CCNfiCuC of Consent to self-insum for Workcls Compen-
sation,as provided for by Section 3'/W of the labor Code,for the performance of the
wo for which this permit is issued.
I have and will maintain Worker
Compensation Insurance,as required by Section
]W of the labor Cndt.for the performance of the work fm which this permit is issued.
My Work ompe anon Ins e orticnnd Polity n
Comer: old lacy y
C. TI TE OF E ION FRO WORKERS
COMPENSATI INSURANCE
(This aectinn recd not he completed ifdoe .it is foronc hundred dollars(Slip)
m Its..)
I eestify that in the perfnmoncc of But work for which this permit is issued.I shall not
employ any person in any manner an as to become subject 0 the Workeri Compersation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,aper making this Ccmficam of Exemption.you should
become Subject to the Work
Worker's Compensation provisions of the Labor Code.you must
�Z forthwith comply with such provisions or this permit shall he deemed revoked,
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a constmnion lending agency for the Performance of
Y. > the work for which this permit is issued(Sec.3097,Civ.C.)
JJ 0 Lender's Name
n.
=,Z Lcndcr'1 Address) 1 ccnify Net 1 have read this application and sum that the eboveinformnion is
Z f"
comet.I agree to comply with all city and County oNiminces and sum laws relating to
ft
�(J building
(We)ti uct,,anvehereby
led...th unit rtprescnmiscs Of ROS ofcciy 10 nmrupnnned
above-mentioned property for inspection puniness.
(We)agree m save,indemnify and 1 fu the Clty of Cupcnino against / �c
to liabilities,judgments.eases and colitoses ich may ins way a<cmt against said City
z APPLICOnat Ain CCNTc of E STANDS ANO a COMPLY WI -PD1 Issued by: Date
SOURCER
Re-roofs
Si re of ApplicanU ono or Dam
H Z DOUSMATERIALSDISCLOSURE Type of Roof
Will the applic ,future building Occupant store or handle hamsdoos mawdtl
u Ccfired by the Cupertino nie al Codc,Chapter 9.12.and the Health=it Safety
Cute,Section 25532(S)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑ o
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or um ilding occupant use equipment or devices which
it hazardous air contrmin not cfined by the Bay Area Air Quality Management all new materials for inspection.
isoict]
❑Yes o
Ihamr,aJthchanmdt sm rials requirements under Chapter 6.95 of the Cali for
Dia Hcalth�Safety Cock,SCetiRL 25585,25533 and 25534.1 unJcrsunJ Not if the building
dors not Cmrendy haw a nL th it u my¢x ny ca nobly t cupant the
regldremenu win 'in et lin rs en cero"7 Signature of Applicant Date
Owner[u amada w All roof coverings to be Class "B" or better
CITY OF CUPERTINO
CQ' FURNACE/ACCrTY OF
3 `
CUPERTINO PERMIT APPLICATION FORM
APN# Date: �O O
BuU4ing Addrgss:'
Owner's N Phone#'
Corjf R � � I Phone: cx � I / License S
Co�n`tt ct:,�/1 Pho D g7 cJ r%� Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ MechRf
Job Descripti
Residential Commercial ❑
For Residential Installations:
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 Planning Approval Required ❑
Cost of Proj Type oMti Occupancy gr p: J
Strapped On Platform El Bonded LJSq.Ft. oor Area: r
New Location ElReplacement El
QtY
Ap9lic 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 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
C BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING