04060150 ct ERE
isionNO PERMITCONTRa,CTO NFORMATION,s
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BUILA PERFECT CLIMATE PERMITNO04060150
78ETTE CT
OW NPERMIT ISSUE DATE
WANG 1057 SNSANITARYNO. CONTROLNO.
(408) 861-9545
ARC : BUILDING PERMrf INFO
L LECs PLUMB MECH
0
uOp LICENSEDCONTRACIOR'SDECLARATION IobDescr o
1 berth,affirm that I am lianscd under pmviam- CMpmr 9(commencing
with Section ).f Dividon Jof Nc eudM..WRof t uCode.and mYlicrnuu
^�a
with
forte. otic. D A/C DEC Z 2004
jgi License
Lim.• L
Dam Con
ARCHITECTS DCLTI
1undcmndmyplans.hallMuupublicmeowsO'U
3mIn Licensed Professional DU
'L®INGo3
OWNER-BUILDER DECLARATION
I hereby el5,m that 1 am exempt from the Com.mofs License Law for she
00 following mason.(Section 7031.5,Business and pmftsecons Code:Any city or county
$ which myuirus,a pcmlil m construct.aloe improve,ticmnlish,or repair any structure
prior m its issuance.also m(omt the applicant for such Permit to Glc a signcd mourner cnt Ft. Floor Area Valuati
� < Muth.is licensed pursuant to the provisions.( s
the cmartuw
rh U..Le.(Craw,9 Sq.
$ (cammeacingwith Secu.n7M )nf Division3offee Bud.csand PmfOdOMCode)m
Nat he u exempt themfmm and the buffs for the alleged exemption.Any violation of
Saturn 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of DId'L1td .5er0 0 Occupancy Type
not more Nan rive hundred dollen($500). .
❑11 as owner of the property,or mY employe.with Wag.as their sole compemadon,
will do lM work and the sromno is mut doemod or offered fmsam(Scs.1041.Budmss ns Required Iactions
and Pofeuiom Code:The Como t Lim^-taw dues MI apply to an war of 9 P
property who Wilds or impowes thereon,and who does such work himscl f or duough his
Own,employ..,provided that such improvements are not inmoAW motioned for to.IL
however,the building.,improvement is sold within one yes,of comPlmOr.the Motor'
builder will have the W,dcn of proving that he did nm Wild or improve for purpose of
sale.).
1.as caner of tie property,.m..bromly convening with licensed comuacmn or
construct
the pmjem(Sec.toad.Business and Pmfessm.Cad =de:)The COhrs Li-
cense Law dux mol apply to an Owner of property who Wilds or improv themon,and
who comment for such pmjceu wife a c.nvactor(s)licensed purmant m the Comnaofs
License Law.
1 am exempt under Sec. .B At P C for Nis mason
Own.
Data
WORKER'S COMPENSATION DECLARATION
I b neby affirm under Penalry.f perjury one of the following daclantimck
I have and will mainum a CcNfmare of Consent to self-insum for Wmkerieompcn-
.uon,u provided for by Section 37M of the labor Code.for the Pc ksork a.f the
woh for which this permit is issmA.
0 1 have and will maintain Worker's Compensation I....u required by Section
3700 of the Labor Code,for Ne performance of the work for which this routine issued.
MyWo C�nmvp�euauon lnsunncc/camcr and Polity n
C 'e v W 'AVL PoIiq No.: r v
C FICATEOFE%EMPrIONFROMWOR
COMPENSATION INSURANCE
reds section need not be Completed if the permit is forolm hundreddollao(SIM)
lea)
1 anify that in the performance of the work for which this Permit's issued.I shall not
employ any permn in my manner so as m become anbject to the Workers Compeuadem
Laws of Calif.mia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should
become subject or the Worker's Compensation previsions of the labor Code,you must
�Q foMwith comply with such provisions or this Permit shall be deemed revoked.
Z CONMUCrION LENDING AGENCY
- '
j-. 1 hereby affirm Wt then is a constroclion Icnding agency for the perform,ance of
C> Ne work for which this permit is issued(Sa.3097,Civ.C.)
W Q Lender's Name
IY Lender's Aidmu
U 0 1 anify that I have tad Nis application and sum Nal dm about infmmatiuo is
W F correct,1 agmm to comply with all city and county ordinances and sum laws sclaung to
0 Wilding construction,emcdtoandhembymir ad keeropmp
of this OfCupy to mmroPonlhe
LU ahoveims,judimond,property for inspection expenses
Purposes. e J
G (We)agree to.w,indemnify and keep harmlcu the City of Cupertino against `/u///%r•///-
fq incoiueajudg,of due .auand of this
may in anyway accrue ageinst.id City
V z in consequence of the gmlting of this permit.
A ANET�UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
s 7)JTZ. (/ , ll1„n„i Re-roofs
Signmur of Applm.VQ mhom I�ILY�t
HAZARDOUS MATERIALS DISCLOSURE Ux Type of Roof
Will the applicant or future building occupant store or handle havudous material
as defined by the Cupertino Municipal Code.aspect 9.11.and du,Health and Safety
mm.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y. 4.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or(mum building by the Bt use equipment Quality
or devices which
mit harardnus air conuminsnu u JCOncJ by the Bay Area Air Quality Managcmcns all new materials for inspection.
Dushict7
0Y. Nu
I have read Ne bavamou.mamrials rtyulremchismder Chapter 6.95ofilm Calif.,
ria Health A Safety Code,Sections 25505.25533 and 15530.1 understood that eft Wilding
docs not c mendy haw a movant that it is my maproubdily tu moil Ile,Occupant of the
rout hie mnstbe all>n/wits .nca,iOf P7,y Signature of Applicant Date
mer.,ambommd agent
Da All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
9 / Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEt�TINO
Building Department
JOB ADDREPERMIT #-Z J i==�
OWNER'S ✓✓ - PHeNE
# l -3 F---
GENERAL
-GENERAL CONTRACTOR: FAX # ' -
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
2)�
\DV r/Contractor Signature at
/ CITY OF C UPERTINO
UPERTINO PERMIT APPLICATION FORM
APN # /� Date:
Building Address:
Owner's Name: Phone#:
Contractor: P one: j �I S License #:
Contact: .� � Phone: Ul Cupertino Business License #:
Building Pen-nit Info: �/
Bldg0' Elect U3 Plumb ❑ Mech 0"�
Job Description: n
Residential l l Commercial ❑
For Residential Inst llations:
Attic ❑ 151 floor A 2nd floor❑
Adhere to min set back requirement❑
or Commercial Installations:
eplacement sanle weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation 0
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occu an group:
Strapped ❑ On Platform ❑ Bonded ❑ U Sq.Ft. Floor-Area:
New Location ❑ Replacement ❑
Q . i
A lic b 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
ff PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Lice L BUILDING
J