03090013 .CITY OF CUPERTINO ,n :*
BUILDING DIVISION PERMIT �CONTRAGTOR INFORMATION.
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olNC ADDRESS: �
Bua _ A PERFECT CLIMATE rEaMIT N903090013
ER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
WADE RQI-1N T. ANT) ('WVNNR
ONE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
J00 LICENSED CONTRACTOR'S DECLARATION
Eu� I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
ii with Section 700)(BlidDivison 3 of Ne Business and Professions Code,and my license is
'=N in full force and
>qz License Lien REPLACE FURNACE-ASC
-Fp Date Contmcmr �®
££uJ ARCHITECTS DECLARATI N
f W U I understand my plans shall he used as public records
S;r
�MLiccnaedProfession.) SEP 2 5>2003
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
02 following mason.(Section 7131.5,Business and Prefessinm Code:Any city m county �'� Q1'•.
g which requires a permit m construct,alter,improve,demolixh,or repair any structure {ssV ry
.ai prior to its issuance.also requires the applicant for such permit to Gln signed statement
Ethat he is licenced pursuant in the previsions ofbcContractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
21—p (commencing with Section 7"1 of Division 3 of the B usiness and Professions Crxk)or
$ Net he is exempt tMrefrom sod the basis for the alleged exemption.Any=of 35624024 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
net more than five hundred delta.(5500). . - - --..--- .... P Y
❑I,a owner of the property,of my employees with wages as their sole compensation,
will do the work,end the structure is not intended or offered for ale(Sec. 044.Business
and Professions Cade:The Contractors Limn.Law does not apply to an owner or Ctions
pmpatty who builds or improves thercon.end who does such work himselfor through his 303 - ROUGH M HP.NI AL
own employees provided that such improvements me not intended ora(fercd for Sala It. 304 — ROUGH ELECTRICAL
however,the building or improvement is sold within one year of completion,the owner.
builder will have the Wrden or proving that he did not Wild or Improve for purpose or 505 - FINAL ELECTRICAL
"l`')' 507 - FINAL PLUMBING
❑ Las owner of the Sec.property,,Business;eulusand contrazting with licensed cmnbamon i. 5 0 8 - F I NAL MECHANI CAL
co mm a Ne project(Sec.7a,a, neofand ay who m Code:)The Conuazmr',rad
come Law docs not apply a in owner of pmpeny who selids or improvm thereon,urs
who contracts for such projects with a comrazmr(q licensed pursuant in Ne Contractors
License Law.
❑Lem exempt under Sen .B,4 PC far thisrcaan
r Date
WORKER'S COMPENSATION DECLARATION
I hereby Ofirre under penalty of perjury ane of Ne following declantima:
I have and will maintain a Certificate of Conant to at Wh ure for Worker's Compcn. _
..
..,an,u provided for by Section 3700 of the labor Code,far Ne performance of the
work for which this permit is iaued.
I have and will maintain Worker'sCompensation Insurance,a required by Section
3 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carticnnd Policy num ra
Cartier. Polity Na.: «�
CERTIFICATE OF E7 NI NFROM ORKERS'
COMPENS NINSURANCE
(Toot taction need not he complo ulifthe permit is for one hundred dollars($100)
or Tess.)
I Certify Nm in the perfoamance Or the work for which this permit is Wood.l shall not
employ any person in any manner an a to hecume subject to the Workers'Compensation
Law,of California.Doc
Applicant
NOTICE TO APPLICANT:Ir,after making this Certificate of Exemption,you should ..
become subject to the Workers Compensation pmvisiom cited tub r Code,you mat
�O forthwith comply with such provisions or this permit shall he deemed tevoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem is a construction lending agency for the performance of
Ya the work for which this permit is Wood(SO.3097,Civ.Cd
YQ Unit.,,Name
Z),z Under's Address
;J 0 1 comfy that 1 have read this application and Sam that the above information is
y (' correct.1 agree to comply with all city and county ordinances and sure laws relating to
DU building construction,and hereby eothorize,representatives of this city to enter upon the
LQ atrove-meXRELATION
ray for inspection Purposes.
(We) ve,indemnif d keep hsrmlc she City of Cupertino against
p) liabilitiesas antla nam hich me any way accrue against mid City
j7 inconseqradin this pe mit.
rr7� APPLICSTA W COMPLY WITH N POI Issued by:9 Date
SOURCE
oafs
Si a fAp Canty mrazmr. Da
HAZARDOUS MATERIALS DISCLOSURE y Of Roof
NcapPlicantur future Wild i amupaas1 nr handle hvudous material
u defined by the Cupertino Moo BU ode,Chapter 9.13,end the Health and Safety
.Section 355330)?
C]Ya All roofs shall be inspected prior to any roofing material being installed.
Will the applicant a uture bui ng occupanl use equipment ordcvice,which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air cmmwmimn as mod by the Bay Area Air Quality Management all new materials for inspection.
isOicR
❑Yes
pw�Rp
aterial menu under Chapter 6.95af the Calder.
Dia Hca35 .35533 25534.Iund ndardi hatiftM Wilding
docs DY sNnahiI ly m It
IM accts ant of the
rcquimretia dont ate or Signature of Applicant Date
ow r nixed rat All roof coverings to be Class "B" or better
�t CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN # Date: "�
/ V
Building Addre� `^
Owner's Name ,( 1 Phone#:
Contracto CA License #- `�
Contact: _ Cupertino Businesls
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description: P � Cy\00A
Residential C' Commercial ❑ 1 "Y
For Residential Installations:
Attic ❑ V floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑ 1
New installation Planning Approval Required
Co f Pygjpct: -qeb Type of Construction�� OccupJtncy group: �f
(J�
Strapped El On Platform onded LJ Sq.Ft. Floor Area—:
New Location ❑ Replacement ❑
Qty. if
A phc 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
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