05010001 CITY OF CUPERTINO
BmtDrncDfvlslon PERMIT: CONTRACT OR INFORMATION
BUILDING ADDRESS: . . A PERFECT CLIMATE PERMIT ND05010001
7588 LO
OWNER'S NAME: - PERMIT ISSUE DATE
SHERRY CHEM
NE:
SANITARY NO. CONTROL NO.
408 861-9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
- BLDG ELECT PLUMB MECH
y Op LICENSED CONTRACTOR'S DECLARATION - Job Description
w❑ I Wrchy affirm that I am littiucd under poviximS of Chapter 9(commencing _
�<W u•ith5 tion] puf DivivonJof the Busi Profcuionx Code,and mylittnse is -
lmm�m derreet, rJa(ry/� FURNACE REPLACEMENT
Z License C (] Lia.A/ n ,
�`❑ Da e0elmma - `,
�� ARCIi1TECTS DELLA lOt �.T
?6U ndcrsund my plans shellruued as pis mmcords .. .- �.�
3 LL G Licensed Professional -
0 OWNER-BUILDER DECLARATION J
<I I mushy affirm that 1 am exempt from the Convano's Licenu Law for the
n o following reason.(Section 703 1.5,Business and Proessiom Cale:Any city or county
P^� which require a permit us ennswm,eller,improve,demolish,or repair any swcturt
ar " prior to its issuance.also requires the applicant for such permit m File a signed statement -
t�'< mar he is licensed pursuant to the pmvisimu of life Contmcmr's Liam,law(Chapter 9 _ -Sq.Ft.Floor Area
ValUati00 -.
FFG (commencing with Section 7")of Division 3 of the Business and Professions Critic)or
to
that he I,exempt therefrom and the basis for the alleged exemption.Any violation of
Section]0]1.5 by am applicant for.Permit aubjcers due applicant o a Civil Penalty of 3 6Q2QQjbfber0 0 - - - -- "— Occupancy Type - -
not mom than Eve hundred dollars(SSW).
❑I,azownv of the property,amy emPloycu with wags azthevmlc compcnsaton, _
willdo Nc work.end Ne swaurt is nos inteMW oronertd faraalclSee]014,Buuircaa
and Prereuiaru Code:The Conuutorer
a Licue Law does trot apply m in owner of Required Inspections _
pommy who Wilihi rimproes Merton,and whiiii. uchwork himselfor WCagh his
.employees.provided thar ouch joh,owmenu are nos intended mofmd formic.If. - - -
howeveeNebuildingorimprove ens ix sold within one car ofcompleum,the owncr-
builder will have the burden of moving that be did nos Wild m improve for purpose of
sale.).
❑I,as no,of Ne property,am exclusively convecting with licensed contractors to -
cmuswn the pmjecs(Sec.7W.Business and Pofusions Code:)The Conuazmr's Li
cense law does not apply to an owner of property who Wilds or improves themon,and. ... ..
who conuacufor such projects with a convacmr(s)licensed pursuant to me Contractors
License Law. 1..1�-
❑1 am exempt under Sec. .B&P C for this moon
weer, Dale
WORKER'S COMPENSATION DECLARATION -
1 hereby a(fno under pini ty of perjury one of dee following declarations:
❑I have and will maintain a Ceninca,of Consent o self-insure for Worker's Compen- -
mton,as provided for by Section 37W of the faro Code,for the perfnrmana of the
work for which this permit is issued.
71 1 have and will maintain Workcts Compensation lommana,az required by Section — - - - -
3]Wofdue Labor Code.for Neperformartee fNe work for which Nu permit is issued. -
My Worke(iEnmpmmd.n insurance =r a icy nu rr am:
I 3 L
Ca cr 'fYkBL�� K ION Na: ,
CERTIFICATE OP EXEMPTIONFROM WORKERS'
• COMPENSATION INSURANCE
films section need not becomplaCd if to permit is(croft hundred dollars(SI W)
nflcss)
I r<nifv Our in Ne perfowence of the work for which this Permit is issued.I shall not
employ any person in any manner am as;in become subjecuo the Workers''Compensation -
Laws of California,Date
Applicant
NOTICE TO APPLICANT:If,after making Of.C,nili ime of Exemption,you should
become subject o m
the WorkCeS Capcouion provisions of the Labor Code,you must
OZ forthwi th comply with such provisions or this permit shall W doomed revoked.
Z O CONSTRUCTION LENDING AGENCY
hw 4 I bereby alErntat Nthere is a conevu .,h,ction lending anry forth,perfurmancc of
Ili 7 the work for which this permit is issued(Sec.JW].Civ.C.)
W A Icndcfs Name
6, Lindeis Address
U O 1 certify that I have mad this application and stain that the move information is
Ty F" correct.1 agree to comply with all city and county ordinances and state laws tutoring In
OU building eonswction.and hereby authotlx mpromentalics Cr this city to enter upon the
r W above-mentioned property for inspection purposes.
F 6. (We)agree to sale,indemni d keep humless the City of Cupenino against
N iiabiliuu,jud mcn¢coau index bows which mey in any way a<cmc agunuuiO City
U Z in Co.sequen sof granting oft is permit. (,
APPLICA U DERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCER GU ATIONS.
Re-roofs
pilfghournme of ApplicanUConvaz'or D te
HAZARDOUS MATERIALS ISCLOSURE Type of Roof
will dm applicant or fu um Wilding occupant Hort or handle hazardous material
az defined by do Cupertino Municipal Code.Chapter 9.12.and the Hcaith and Safety
ode,Seed,n 25s3z(,)] /la� : All roofs shall be inspected prior to any roofing material being installed.
❑Yes t a�yNa
win mea n,.m or mom building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
pp s v 4uipmcn
waaa ,mil hazardous air contaminants u defined by Ne Bay Area Air Quality Management all new materials for inspection.
DisuicR
❑Yes /6u
I have mol NcnmamRus or
requimmcnts under Chapter 6.95ofNcCalifor-
niaRcalth&Sarcty Code Sccuo 8 .25533andM34.1undcrsund W.,i(thc Wilding
does not euro el naw a tenon that It's my osier lblllly o nosily dee occupant of dh,
requiremcnta n bmvslbemc pdoru iuuanccofaccarFi aIacapaney. Signature of Applicant Date
t All roof coverings to be Class"B"or better
Owner Or momlircd agent ate
Community Development
10300 Torre Avenue
J, Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT #
1696 ,-( D o
OWNER'S NAME: h PHONE #
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 7-Z3/5?
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
Til
Owner/Contractor Sign iture Da et
CITY OF CUPERTINO
FURNACE/AC
UF
UffikTINO PERMIT APPLICATION FORM
APN# D e:
Building Address:
0 k
Owner'$ Name: Phone #:
h 09)a6O
Comactor- Phone: ticense#:
Phone: Cupertino Business License#:
Building Permit into:
Bldg ❑ Elect AD Plumb ❑ Mech
Job Description: /
Residential Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2"d floor❑
dhere to min set back requirement[]
or Commercial Installations:
eplacement same weight ❑ ; Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningA royal Re uired ❑ -'
Cost of Project: Type of Construct P- Oc pancy P'.`ea SOa I
Strapped ❑ On Platform ❑ Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
if
,A(p-p4abl,p Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit-> 10,000 cfrn 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
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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