04070138 CITY OF CUPERTINO ('� "j'�. 7 "7" 77 771"(�FT1r14e,
� , W,1r0",'
BUILDING DIVISION PERMITQl�r`1 ^�I"i•" �Fa.J.Ag4F'"
pU1LDING ADDRESS: _ A PERFECT CLIMATE PERMITN00407.0138
49c; MC CTEMLAN Rn
OWNER'S NAME: PBRM1T 155UEDATE
INGU C
ONE: SANITARYNO. CONTROLNO.
408 861-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
TED
LDG ELECT PLUMB MECH
0 0 0 0
LoiC] LICENSED CONTRACTOR'S DECLARATION Job De5CT1pUOn�
uq 1 Wrcby affirm that I am licensed under provisions of Chapter 9(commencing
r ZV.S. with Section7000)ofDlvislan 3 ofthe Business and Professions Code.and my licenecis
EEEEE. inm.ClAAAnderc ,Zvj(SES' REPLACE FURNACE & ADD A/C �� ®
n�Z License Class Lk.g
1 Dam Cumrm o r -
1 p W ARCHITECTS DECLARATION 7 2004
u„IS 7 1 understand my plans shall he used as public records JUL "•
D a s�
LiccnmI hereby oval soli t�iNG
OWNER-BUILDER DECLARATION Ys0 sR`atltl�B
gy 1 hereby
affirm that 1 1. exempt from IW Contractors License Law I'm the
S:19 which following n.permit(Sectito 9D L5.Business and prove,a imil h.or: ,at,ily a l.ho y
.J$ which requires a permit m cnnswct,alcor,improve,demolish,m repair any mmmum
iz�� prior to its issuance,also mquimumit he applicant far such perto rile a signed statement
that he is licensed pursuant the provisions of the Common's Licance Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business antl Professions Code)or
'� .. that he is exempt therefrom and the basis for the alleged emmpton.Any violation of
'Section 7031.5 by any applicant for a permit subject use applicant o a civil penalty of 3 5kTN3fU5 ber0 0 Occupancy Type
Tn'o`,...then five hundred dollen(S500).
F]9,m owner of the property,Or my employees with wages As their sole compensation,
will do the work and thestructure is not intended oroQered for aale(Sm.7094,Business
and Profusions Code:The Conummrs Liam Law doei'not apply to en owner of Required Inspections '
property who builds or improves thereon,and who das such work him self or through his
awn employe.,provided that such impms unamas ere not intended..offered foraale.If.
however,Ne building or imp revemcut is sold within one year of mon,twOma,Neowner.
builder will have the burden of proving Nat W did not build or improve for purpose of
.lees).
❑1.as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.70".Business and Professions Code:)The Cauracue s Li.
cense Law does not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such pmjecu with a conlractor(s)licensed pursuant o the Contractors
License Law. -
❑Ismexam net�Se/e. ` ,B&PCf rfloa on
Owner �,y/L��! ft Date -
--WOR ER'SCOMPENSATIONDECLARATION
1 hereby af0rm under penalty.(perjury one of the following dttlentionm
1 have and will maintain a Certificate ofConant to self-insure for Worker's Compere
rm
Action,as provided for by Section 3700 of the LSr Code,for the perfoance of the
work for which this permit is issued.
I Ave and will maintain Worker's Compensation Insurance,as re uimd by Sector,
of the Labor Code.for the performance of the work for which Nis Permit is issued.
My Workers Cnmp�e.ai nn lose nm camicr and Poliry nu ber ate:
Cartier. �- Policy No.: ,,
CERTIFlCATE IF EXEM ON FROM RK RS'
COMPENSATION INSURANCE
(This section need not W completed Hthe permit is foto.hundred dollen 96100)
m less.)
I certify that In the performance of on,work for which Nis permit is issued.I shall not
employ any parson in any manner.as to Wcome subject e Ne Workers'Compensation
Laws of California.Data
Appllcant
NOTICE TO APPLICANT:If,after making this Certificate of Eacmpti m,you should
become subject in the Worker's Compensation previsions of the Labor Code,you must
.JO forthwith comply with such provisions or this permit shall W deemed mvnkcd.
„z„► CONSTRUCTION LENDING AGENCY
r I hereby affirm that them is a construction lending agency for tW Performance of
the work for which this permit Is issued(Sec.3097,CN,C.)
W A Leader's Name
Z Lender's Address
V I ceNfy that 1 have rad Nis application and smte that We about information is
W(~ coned I agree to comply with all city and county ordinances and state laws relating to
OV building consnuctian,and Wray mthorlm representatives of this city to enter upon the
W ahove-menti ned property for inspection purposes
92. (We)agree to sass,indemnify and keep harmless the City of Cupertino against
,, liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. r
s..i APPLICANT ERSTANDS AND WILL COMP6Y WITH ALL NON-POINT Issued by: Date )b:�L
50 RCE TION —7
�� Re-roofs
Slinmure 6f App man/Conurne., Date a of Roof
HAZARDOUS MATERIALS DISCLOSURE Typ
Will the applicant or future building occupant store or handle hmmdous material
as dented by the Cupertino Men cup.)Coda,Chapter 9.12.and the Health and Safety
IDtan,t?
Jc,Section 25532(x)? tj All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the Apple, r future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haimous air contaminants As dc0ned by the Bay Area Air Quality Management all new materials for inspection.
4
❑yes �No
Ihave rcml the hvaNasmateriabrcquiremcntsunder Chapter 6.95 of the Califor-
Health&SafetyCade.Sccuom 25505.25533 and 25534.1 tomarand that if the buildings t currently has.atenen4 Nat it is my rcapo.ihiliry m notify IM occupant M Ne
s gntswhi mut. tax ar eemneamoroeeancy. Signature of Applicant Date
Owner or aamorived agent �Gl�/� >-o> All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
aClOF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS- 2 ('2 dlPGLIERMIT #
Z � 1
OWNER'S NAME: �� /� PHONE # $=2 5 7— 5
GENERAL CONTRACT FAX # _ 5
I am not using any subcontractors: Ktl� Z
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
4OLandscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
� Z �
Owner/Contractor Signature Date
CITY OF CUPERTINO
OF
UPEkTINO PERMIT APPLICATION FORM
APN # � �OC /�1G j Date:
Building Address:
Owner's Name: 1 Phone#:
AIA L OK 7—(Q 7,
Contractor:1�( Phone: License #:W -96_'_nf�- S ?23/f�g
Contact: Phone: Cupertino Business Lice
nse #:
Building Permit Info:
Bldg ❑ Elect LLQ Plumb ❑ Mech 2---
Job Description: * add
Residential [� Commercial ❑ (�
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor�
Adhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑ f
New installation Plannin A royal Re uired ❑
Cost of Project: q Type of Construction: vo— Occup a cy gr i
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. oor Area:
New Location ❑ Replacement ❑
Qt . tf
ApulicaklFeeID 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 c&n 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
x/71- �