04020109CITY OF CUPERTINO''"*
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Hun.nmc Dlvlsloly PERMIT
<CQNTRACTOR`INFQRMATION
BUILDINGADDRFSs:
D4A-R DR
SUPREME AIR SYSTEMS
PERMITNo04020109
OW NER'S NAME:
PERMIT LSSUE DATE
ONE:
SANITARY mrol. NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Wmhy affirm thin 1 am licen.d under provisions of Chapter 9 (commenting
P
with Simon. 7=*.f Division 3.f me Business end Promemm. Code, and my license is
in full fore and effect.
REPLACE FRUNACE (GAS-)
License Class Lie,.
Date Contractor
I(��
a+ YZIZ
ARCHITECT'S DECLARATION
I understand my plans shall be used as public reenrds
FEB 1 8 2004
Licensed Pmfcuional
DECLARATION
Oat
I a. m.,t fir
I hereby maso affirm tent 11. exempt frum the Contractors License Law far We
following Business and Code: Any city or county
D�II�n yy�
sae, demolish. any structure
mquireon.(Scchto ensu alto improve, demolish,
which leyua pctmio m
which
UVJ L,l L[.fJ
fie a sig
requites the applicant for such permit m file a signed statement
prior us its issuance. aims the
Sq. Ft. Floor Area
Valuation
easedralso
Nat r'sLimnmlaw(Chapter
of Division3 ortheeged cseand ode)or
menccensedpursuantmtheorDivisrmofofthe8infir
(commencingWith
VilatNe)Or
amfSection
rm and on.An
Net he u exempt therefrom and We buts for the alleged emmpthm. Any violation of
36V1101iftteff)0
Occupancy Type
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
not mom than Eve bundled dollars ($500),
❑ 1. six owner ofthe property, or mycmployeas with wages as theirselecompenasonn,
Required Inspections
will do We work, and Ne swaure is not intended.,offemd far sale (Sec. 1064, Business
and Professions Code: The Conwc orb Licnum Law does not apply to an Owner .f
property who builds or improves themon,and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for.le. If,
however, We building Or improvement is sold within one year of ec mpled.n, We owner.
builder will have We burden of proving Nat he did not build or improve for purpose of
sale.).
I, a owner of We property, am exclusively contracting with licensed contractors to
nRof et the pmjen (Sec. 7W, Business and Professions Code:) The Commons Lb
cense law does not apply to an owner of property who Wilds or improver themon, and
who contracts for such projects with a comonmr(s) licensed pursuant to the Con orelm a
License Law.
❑ I am exempt under Sec. B & P C for this reason
ow cr LA i�1—�.Dom Z
R 'S CO ENSA ONDL N
I hereby aPnm under penalty of pefjury one of the gdecimations:
1 have and will maintain a Cenifcam of Consent to selbinsum for Workers Cumpem
..on, u provided for by Section 37M of the labor Code, for the pe Hormenco of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as requited by Sectio
3100 of the labor Code, for We performance of We work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This amiian need not hecompleted lithe pconit is for m c hundred dmpost ($101)
or less.)
1 minify that in the perrormanee or We work for which Nis permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Ccri fleam of Exemption, you should
become subject to We Worker's Compensation previsions of We la nor Code, you must
f.Mwith comply with each poli or his permitshall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a eonsto ctinn lending agency for the performance of
We work for which this permit is issued (Sec. 3091, Civ. C.)
Lender's Name
Lender's Address
I certify Nat 1 have mad this application and surto Nat We above information is
camel. 1 agree to comply with all city and county ordinances and state laws telling to
building construction, and hereby auNorire representatives or this city to enter upon the
.hove -mentioned prepcny for impeedon purposes.
(We) agree to save. indemnify and keep harmless the City of Cupertino against
liabilities, judgmcnu, casts and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
SOURCE Rc U ATIONS.
Re -roofs
Type of Roof
//J I dim/� 1i
0armeor 0canb on men.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furem building Occupant store or handle halem ous material
aarmed by We CeNnin. Municipal Code. Chapter 9.12, and the Health and Safety
me, Section 25572(01
All roofs shall be inspected prior to any roofing material being
CYea of.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fumm building Occupant use cquipmenl or devices which
. mociom us ai,commitments . dcfincd by the Bay Am. Ail Quality Managcmcnt
all new materials for inspection.
Di uici?
❑Yes rNu
I have mad We huma xim s mmcrials requirements under Chapter 6.95 of the Caller.
nia Hca IN&Safety Conk, Sections 25505, 25533 and 25534.1 undersand ma fifth Wilding
docs not currndy M1mx a anter, Nm it u my responsibility m nod a of rho
re it cnka mmhm.atbeme poor i�.an.e.rae.nifea¢.fa a eary.
Signature of Applicant Date
vI
All roof coverings to be Class "B" or better
el Owner
or amoucled agent Dmc
U
U
`J /Ab " v h
I am not using any subcontractors:
Signature Date
�„rl rmmnlata iha WInwinv information:
Owner/ Contractor Signature
10/28/03
Z 17 Z 0
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass/ Glazing
Heating
5 �MA AIX S icEA-c;Ub
6
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
10/28/03
Z 17 Z 0
Date
9,5L�-a _ qG (�
C7
El
11
OF
cm _T
CUPEf�TINO
CITY OF CUPERTINO
]FURNACE/AC
PERMIT APPLICATION FORM
APN # / ° l
L�
Energy
T/ e
Building Address:
�11 3 W/ MAIC Gtn 6i9-r(tJO ( L
Relocation of Furnace
MECFIANICAL
-�T
Owner's Name:
Auris I WA1J6
MECFIANICAL
Phone #:
WOO- IS 2- W7S-1
Contractor:
SU nL-mt, A+(L
MECFIANICAL
License #:
'74-0
Contact:
ELECTRICAL
Cupertino Business License #:
Building Permit Info:
BUILDING
EPERMITFEE
Bldg ❑ Elect ❑
Plumb ❑
Mech ❑
Job Description:
�epie��t 60 4-,W,C-C-�
MECHANICAL
Residential Commercial ❑
Plumbing Permit Issue
PLUMBING
For Residential Inst Ilations:
Bldg Pen nit Fees
BUILDING
Attic ❑ 1" floor 2"d floor ❑
Plan Check Fee
BUILDING
Adhere to min set back requirement ❑
Business License
BUILDING
For Commercial Installations:
Replacement same weight (r Additional weight
(structural cales) ❑
Structural Calculations required for new installation
❑
New installation Planning Approval Required
Cost of Project: Type of Const
on
Occupancy grot
Strapped LJ On Platform LJ Bonded
Sq.Ft. Floor A
New Location ❑ Replacement ❑
Qty. if
AppjiEDje
Fee ID
Fee Description
Fee Groun
ENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECFIANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECFIANICAL
BREMAIRFIAN
A/C Units <= 10, 000 cfm
MECFIANICAL
BREMRECEPT
Rec tl, 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 Pen nit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
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