03110020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ?CONTRAC�TOR�INFORMATI10'
W—ABUILDING ADDRESS: A PERFECT CLIMATE PERMIT N003110020
10092 MANN DR
OWNER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
igh DENNIS WIANTMAN 11/04/2003
NE: (408) 861-9545 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECii
0 0 0 0
£oo LICENSED CONTRACTOR'S DECLARATION JobDeScFMAL "EO
U� w I thereby a(rirm IM1et 1 em licensed under previsions of CWprer Y romancing
iIn Sec tion] n3or NC Business and Pr ions o a an xis
immB ram on r LACE FURNACE 2 2 2003
Lice o N DEC
Dam Cunman
q ARCHITECTS❑
£Wl understand my plamahW all aurc
audits public erads
U
Licensed Pn(tribunal BUILDING
OWNER-BUILDER DECLARATION
<f 1 hereby affirm that 1 am exempt from Ne Contractor's License Law for the
p O following mason.(Section 703 1,5.Business and Professions Code:Any city or county
5$ which requires a permit to eomu ict,alter,improve,demolish,or repair any structure $2255
prior or its issoance.also mtuirts the applicant rorsuch permit to rile asignedsitemenl
< that he is licensedpursuanttotheprovisionsortheContrscmr'sLicenselaw(Chapter9 Sq. Ft. Floor Area Valuation
FO (commencing with Section 7000)ofDivision 3ofthe Business and professionsCnde)lir 32419004 . 00
$ that he is eaempl Ihciefrom and Ne basis for the alleged exemption.Any vinlalion of
Section 7031.5 by any applicant for a p,rri subjects the applicant to a civil penalty of ppN Number Occupancy
nut mom than five hundred dollen(S50B). P Y Type
❑1,as owner of the progeny,or my employees with wages as their sale compensation,
will do the work.and the station,is not intended or offered for sale(Sec.7044,Business
and Professions Code:no Com actor's License law docs not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himselrm through his
Own employees,provided that such improvements art not intended or offered for sale,if.
however,the building or improwment is sold within am oar of completion,Ne owner.
builder will have the burden of proving that he did oat Wild or improve for purpose of
.ie.).
❑1.as owner of the prolixity,em exclusively contracting with licensed contractors to
contact the project(Sec.71144,Business end Proressiom Code:)The Co.=.,,Li.
cense law docs not apply to in owner of propeny who Wilds or improves themon,and,
who contracts for such projects with a conscaaor(s)licensed pursuant o dm Comraetofs
License law.
l and exempt under Sec. ,B&P C for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Be fallowing declarations:
1 haw and will maintain a Ceniricom of Consent to self-insum(or Worker's Comfort.
retia ,m provided for by Sectio 3700 of the Labor Cade,for the performance of the
o forwhich0dispermiti,iasucd.
haw and will maintain Worker's Compensation Insurance,Or required by Section
or the Labor Cods,far the pvrfurmmec of the work for which this permit is issued.
Y mrke'a oro s in Imo ne ni rand Policy nit � ,
Cartier. icy Na.:
CER IFICATEO ION FROM ORK RS'
COMPENSAT INSURANCE
(nif,.,,I.need not W romplem the permit is for one hundred dollars(S 1011)
as.)
I certify thin in the performance of the work for which this permit is issued.I shall no,
employ any p rnsum in any manner sit as in hecume subject a but WOrktrs'Comrkmod on
Laws of Caltromia.Dam
Applicant
NOTICE TO APPLICANT.IL after making this Cenificam of Exemption,you should
became Subject m the Worker's Compensation provisions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall W deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is convection lending agency for the performance of
O: the work for which this permit is issued(Sec.3097,Civ.C.)
fz1 A Lender's Name
= z' Lender's Address
U C) I cenify Nat I have read this application and mm that the above information Is -
Fcancel.1 agree to comply with all city and county ordinances and sum lawi mining to
V Wilding convection,and hereby emhorw mprexnmtiw of this city to Colorupon the
D3 shove-mentioned prorcny for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA IioAcon
%.Coals and expenses which may in any way accrue against mid City
V z in he grami his permit.
ADERST NDS ILL COMPLY YII ALL ON-POINT Issued by: Dat
O //
licaRe-roofs
HAZARDOUS
iCnalure por pe
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
1 the aapplicant m future Wal Cu t,Chapter
smm or handle Health
mamrial
m defined by the Cupertino Municipal Code,Chapmr 9.1 i,and the Health and Safety
Code.Section 25533(x)? All roofs shall be inspected prior to an roofing material being Installed.
r]Yea No P P Y g g
Will the applicant r fat ne building ottapanl use egaipmenl Cr devices which If a roof is installed without first obtaining an inspection,I agree to remove
of haardnm air conmminan (ed by the Bay Arca Air Quality Management all new materials for inspection.
Id.
❑Yea1have mail Ne hmnNres materials requirements underChapmr 6.95 of0c Califor.
HwOh&SafctyCock,Sectons 25505.35533 and 25534.I understand data fthe hi ili ing
not cunen0y have a nam Nat itis my maroon 1d,ly notify he occupanl of the
imm,mlswhich a nor uldiccofa r 'u ,Ty. Signature of Applicant Date
ner lir Sul rcJ agentDateAll roof coverings to be Class aB„or better
CITY OF CUPERTINO
Sonn3 � ( �-� 2-0FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # ON
Date
Building Ad ss:
Owner's Nam
Contror: Phon : icense#:P24 /
Cont ct: Phone: Cu erfino Business License #:
Building Pernut Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description• '1 nn�
Ike CP
Residential Commercial ❑
For Remg�sidential In Mations:
Attic u I" floor � 2nd floor❑
. Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningApproval Required ❑
t of Project: Typ f o s ction: Occup nc roug;,
trapped On Platform ❑ Bonded Sq.Ft. o r .
New Location ❑ Re lacemen
Qty. if
A li e Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAI HAN 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
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