03080018 I CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRA' U-10RIINFORMATI®N #
BUILDING ADDRESS: A PERFECT CLIMATE PERMITNO0308OO18
OWNER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
Alk WILLIAM TING
Q8/05/2003
ONE: (408) 8'61-9545 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
+Oo LICENSED CONTRACTOR'S DECLARATION 0 Job Description
I hereby affirm that 1 am f ilm Be ander provisionslr, of inapt.r v(commencing ing p
fi� with Scairn]IXN)) of the Busin eandP fcuinne Cndc,a, myli<cnu is
full fn.a.ne cfM 7 ADD A/C
j,uJ? Liccnu Clain—�Lic.11
i4p Date;Leyp�_Curer'tor
WS W U I understand my plans shall W used as public te r
[Orn Licenced Pmfwsimel
'01
OWNER-BUILDER DECLARATION e Z MM
2<7 1 hereby airman Oak I am exempt from the Contractor's License Law for the AUGbl{I (1 (�1�1
00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
uw which myuirex a permit I()construct,alter,improve,demolish m repair any.structure $2988
°iy poor m ice issuance.also rtquires the applicant for such Permit to file a signed matement
.SG that he is licensedpu..nuntheprovisionsoftWContractorsLicenulsw(Chaple,9 Sq. Ft. Floor Area Valuation
Ca' (commencing with Section 700ID)of Division 3 of the Busi ness and Professions Cudc)tar
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 37526047 . 00
Section 7031.5 by any applicant for a permit subjects to applicant ro a civil Penalty of
not more than Eve hundred dollars(s500), - APN Number Occupancy Type
0 I,as owner of the pmpcny,or my employees with wages as their sole ermper admn,
will do Ne work,and Ne awnute is not intended orolfered for sale(Sec.7041,Busineu —
and Professions Code:The Comreemex License Law docs not apply to an owner of (IODS
propertywho builds or improves hereon.and who does such work himself or through his 303 — ROUGH L
..employ..Provided ho such improwmenu arenmintended m.frafed for sale.If, 304 — ROUGH ELECTRICAL
however.me building or improvement is sold within one year of completion,the Owner-
builder will have the burden of proving mat he did not build or improve for purpose of 505 - FINAL ELECTRICAL
01, 507 - FINAL PLUMBING
❑Las owner a the property.,Business exclusively convecting with licenced nnv tor's m
comwatheprojot applytoi tradeor
prty who
thereon.Li.
SOS — FINAL MECHANICAL
cave Law docs r s apply m ts owner of proper(who Wilds or improves Norton,and
who contracts for such pmjcev with a convector(s)licensed pursuant to the Convaarh
C use
Law.
I aexempt under Sec. B k P C far Nis mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirmunder penalty of perjury ane of the,following declarations:
I new and will maintain a CcOficue of Consent to self-insure forWorkcriCompcn-
cation,ss provided for by Section 37M of the IJWr Code.for the peffineno a of the
re for which this permit is issued.
have and will maintain Winker's Compensation Insurance,as required by Section
7 of the LaWr Code,for to performance of the work for which this permit is issued.
My 'it,`1Cnmpemation nsumnce carrier and Policy ggqµµqqqu99lIr
Camcr:Policy NO M W I G
I ICA OFE EMPTION FROM KERS'
COMPEN ATION INSURANCE
(ITU uctiml moil not W completed if the Permit is for we hundred dollars ISIIt
or less.)
I ccnify that in the performance of the work(of which this Permit is issu d,I shall net
employ any person in any manner an as to Wmme subject o the Workers''Compenution
Laws of Califon est.Da¢
Applicant
NOTICE TO APPLICANT:IT after making Nis Certificate of Exemption.you should
Weome subject to the Worker's Com NMLion provisions M the Labor Code,you must
�z forthwith comply with such provisions or this permit a hall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
l hereby alarm that there is a construninn lending agency for the performance of
the work fur which rets permit is issued(Sec.3097,Civ.C.)
Q Lenders Name
Z Under' Address
1
:-3 Q I ccnify Our I have reed this application and slate that the above information is -
1 F coreca 1 agree to COM with all city and county oNifmntts and Crete laws r upon t e �JC)
J O 'twongeonamsd p d herebyeuthofiae repsesenutims tar thiscitymenmrupon the
ty
Z in con mcntrice, p ranfor ins it p !poses.
p3. (Weex,p agrees :arc,indent y and p humless the City of Cupcnino againry �^ T^ ��
h liabilitiu,judgme .cosy anile nses ich may in any way accrue againsteud City
J z in umseyucncc c Braining this per it.
.. SOURCE GUAPPLICA NAERSTAN/A D ILL COMPLY WITH AL NO POINT Issued by: Dale
nfirlo Ap is VC Re-roofs
I ]te
HAZARDOUS MATE LS DISCLOSURE Type of Roof
Will plicatetar future siding occupant store or M1andI.haaardoasmaterlal
as derided by c Cured Munn al Code.Chapter 9.13,and the Net and Safety
Code.Sctio 5532(.)?
❑Yea N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fu r Iding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hasardnus air canmmi no defined by the Bay Arca Air Quality Management all new materials for inspection.
isvict?
❑Yca
have mad the aaNnusmater' vimmc 5534.1rChapter boor it
ttheWriiing
dies Hco,c Safcl ,Sccuom ore MS!"m553dtYroo standthmiflW Wilding
Dors not v' y a moan al it u y fcspomihility m notify the meupvit of the
,eq., em.whi mstW tpdmm'Ouncenf cru0c""o
i Signature of Applicant Date
Owner or te agent 1 11patf I All roof coverings to be Class "B" or better
I' CITY OF CUPERTINO
" PERMIT APPLICATION FORM
APN # Date:
Buildin Address:
I�
Owner's Name Pho e #: 1
Contractor: Licensee
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description
Residential Commercial ❑
For Residential Installations:
Attic-5' I" floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
• For Commercial Installations:
Replacement same weight ❑ Additional weight(structural cales) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Coof Pro ect� Type Construction: Occyp�c group:
Strapped Ll On Platform I Bonded LJ Sq.Ft. Floor Area:
New Location ❑ Re laceme
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 ti, Switch & Outlets ELECTRICAL
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
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