04030201'
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CINTRACTQR i1VU�t1.'�IQNa�:
BUILDINGADDREss:
A PERFECT CLIMATE
FmmiTNo04030201
10534 METROR PT,
OWNER'S NAME:
PERMIT ISSUE DATE
Id
Ih ALLEN SYNDER
11
ONE:
SANITARY O. 0 OL NO.
408
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGO ELECTO PLUMB MECHO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 by affirm the 1 am I-cemed under mv'aians of Chapter 9 (commencing
wlm Sec 7 )ofDiviaio.3 of mo Basun Profcuions Code. and mylkwe8
men r° a t. S
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REPLACE FURNACE & ADD A/C FINALE®
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1 un ed—nulld my plans hal M uud as public rtenMs C t
MAR 3 0 2004
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Professional
nLicensed
e
OWNER -BUILDER DECLARATION
1 hereby aRrm that I em exempt from the Convanola License Lew for the
BUILDING
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following mason. (Section 7031.5, Business and Professions Cale: Any city or county
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which requires a permit to construct. ellen, improve, demolish. or repair any structure
prior to its imuance. akar requires the applicant rorsoch permit to fdeasigned statement
that Wiskicensedpursuant to the previsions ofOro ComrmutesLicense Law (Chapter 9
Sq. Ft. Floor Area
Valuator
FD
$
(commencing with Section 7010) of Division 3.f the Business and Professions Cale) or
that M Is exempt thcmfem and the basis for the alleged exemption. Any violation of
3 2W4141iih>DerO O
Occupancy Type
Section 7031.5 by tory applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($500).
❑ I, as owner of the properly, or my employees with wageas theirmle compensation,
Required Inspections
will do the work and the southern isnot immnded aranered forms (Sec. 7066. Biomass
and Professions Code: The Comrscore License law does not apply to in owner of
prope rty w ho Wilds or improve theman, and who dues such work himself or through his
own employem, provided that such improvements me not intended orolfned formle. If.
however, the building or improvement is mid within am year of completion. the owner.
builder will have the burden of proving that he did net build m improve fa purpose of
sale.).
❑ I, as owner of the property, am exclusively cnnvmting with licensed anwcrots to
construct the project (Sec. 7066, Business and Professions Code:) The Conmctar's Li -
came law does not apply M an owner of paunchy who builds or improve thereon, and
who oenvacts for such projects with a contractor(s) licensed pursuant to use Convector's
License law.
❑ I am exempt under See ,B&P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby Allem under penalty of perjury ane of the following declarations:
1 have and will maintain a CeniOmto of Consent to self-imum for Warker's Compere
ad.n, m provided for by Section 3700 of the labor Cade, for the Performance of the
.,it for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Works, shipment, In mance carrier and Policy number am:
�C
Carrier
CERTIFICATE OF EMPTIO MWORKWORK ERS'
COMPENSATION.? ANCE
CMN section need not he completed if the permit is far ane hundred dollars ($100)
or lam)
1 ceniry, that in the performance of the work for which this permit is Wood, I shall not
employ any person in my mater so as to became subject o tie Workers' Compensation
Law. of California. Data
APPlicanl
NOTICE TO APPLICAND IL alter making this Couricare of Exemption, you should
mcomc subject to the Worker's Compensation provisions of this labor Code, you must
fa Awith comply with such provision or mix permit shall he deemed revoked.
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y
CONSTRUCTION LENDING AGENCY
I hemhy Alum that them is a consauction andingagmwy forthe romiurmanceof
'
Hthe
work for which this permit is issued (Sec. 3097. Civ. C.)
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Lender's Name
Lender's Add.
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I certify that 1 have mad this application and sum that the above information is
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toren. I agree to comply with At city ad county ondinanca and sum laws minting to
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building construction, and hereby authorise mprcunativm or this city to tamer upon the
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above-mentioned remarry for inspection purposes.
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(We) agree an ave. indemnify and keep hurdlers the City of Cupertino against
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liabilities, judgments, costs and expenses which may in any way account against mid City
in consequence, of the grating of this
%Date
r7y
permit.
APPLICANT UNDERSTANDS AbJD WILI, COMPLY WITH ALL NON -POINT
Issued by:
ATIO3a"3
Reroofs
Applicaut Convector DataHAZARDOUS MATERIALS DISCLOSUREType
of Roof
me applicant or future building occupanlsmat or handle hazardous material
rSoUREGG
the 32(.)?moo Municipalpodc,-Chapkr 9.13, and the Ncalth and Safety
35533(a)?/'rNaNAll
s
roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
me applicant or future building occupant use equipment or devices which
o ail camrminans armed by the Bay Area Air Quality Management
all new materials for inspection.
ef
❑Yes ON.
Ilt c mad the haamrmsmakfiaHrequiremc is derChepmr6.95afthe Califor-
niaHcolm&Safely CMe,Sationsg55o5.25533 536.1 updcrsmnd thuifthc building
does not aurally loop s roman, JAal It u m an a huhty to nor he occupat of the
'isG
mquimmenl which us( be met pnori c ac'el upancy.
k� a
�ignpture of Applicant Date
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All roof coverings to be Class "B" or better
Owner or thonzed agent Data
aClOF
`UPERTINO
Buildine D
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
JOB ADDRE
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GENERAL CONTRACTOR rFAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and comvlete the followine information:
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Date
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SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
e CA VV01je
I/
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
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Date
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MY of
CUPEFZTINO
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CITY OF CUPERTINO d� �D/
FURNACE/AC
PERMIT APPLICATION FORM
APN #� -OIL-(
Da . a5 -O
Building Addres
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Relocation of Furnace
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Cupe�ttno B sines License #:
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Buildin; Permit Info:
BREMRECEPT
Bldg ❑ Elect �/ Plumb ❑
Mech
Job Description-
�Ci Cc,�la� � �YL� \V1 SLjC(`s�l v1 �ocai�
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Residential Commercial ❑
BUILDING
For Re idential Ins Mations:
Lj
Elec Permit Issuance
Attic I" floor L 2nd floor ❑
( MPERMITFEE
Adhere to min set back requirement ❑
MECHANICAL
For Commercial Installations:
Plumbing Permit Issue
Replacement same weight ❑ Additional weight (structural calcs) ❑
BPERMFEE
Structural Calculations required for new installation ❑
BUILDING
New installation lanni A Required
Plan Check Fee
Cost oY Pro' ct: Type of Construction:
4 �,51� 2Co �Ue—�C,
Occup cy pr
3irappea ts�rm u nonaea u Sq.Ft. Flims :
New Location ❑ Replacement ❑
Qty.�
ADDltaaiSiel
Fee, Ili
FPP npeG,;ntinn r- /7........
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
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