05020002 CITY OF CUPERTINO * ^- vs Au+';a r * � ""a �•�'��°�"
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: A PERFECT CLIMATE PFRMRN.05020002
9-7 NC)PTPPRr)nK SC)
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
408 861-954
ARCHITECDENGINEER: BUIIDIN0 PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION O O O O
u I hereby affirm this i am licemed under pmvWons of Chapter 9 mmmcmmg Job Description
with Scetion 7")ofDivi Tan 3 afthe Business and Profacions an my lice.is
6 In full foM1Y and effC[L �9d�
sn? Lica so C11. Lic.g r� /�') ADD ASC
mH Dao: Canmmm
,e ARCHITECTS DECI:URA ON
1 undcn and my plansshalUwaud'u pub0e t
�yU
Lkcnud Pmfusionel
3 Oat I am exempt
from
DECLARATION
i p 1 hereby strum(Saturn n 1 am ucmpt from Ne Conaum/s License taw for the
followy p which ins rt.aermitt7f.l.S, 4 Business and approve.
Professions Code:My city sonsc my
which reyusu a permit m quires due alter,ire pmsu hPermitt fi repair any tawarure
FZy
prior u)iuiensedpalso requires due of forthe Contractor's
permiuricensle ae ned Law(Chapter
_
irk$< NalxammemliwitpSmileuOflu:provivision3 fdimB sines ndI'mclaw(Coast)9 S Ft. Floor Area Valuation
(mm cis exempt
pth Section Tang of Divfsion3 of aeeged Business.Mon.myons Coast)orq
,hal he u uempT Bmrefrom and Ne bmb for Om alleged Gumption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 2A0,Pl@L'ffi 3e0 ane 0 Occupancy Type
not more man five summit dollars($5o0). p y yp
❑Luavner .the poprny,omye imemia withrvaguuthe'vuk eompemness
will domework.ands:The isrunmious'smm�dad orawd donatepply town Business
and Ryes bis code:The canmcmr's License Law does ool apply lf an owner of Required Inspections
own erywho mildsviimposesch improvements
andwM doesouch woe himselfedthrough his
awn c err,the Wiping or
mal such improvements am not intended oroBcrW for nle.IL
however,Nc building car impmwmml isowithin arc year of mmpleuo the owner-
Duildcr will haw dm burden of provingm&,
vins at he did not build or impmw for
PURom of
tile.).
co 1,as ower of project
Sec.pro7 .Business sed and Professions wire:)To C ods exmrs .
construct are es ran (Sac.o an woofand Professions Code:)M Cs Osman, n /
come law arcs not appy w an owner of property who builds or impmvu Thereon,and 0
who contacts for such Projects with a conussmr(s)Iicenu0 pursuant to the ConeacloYs �\
Licence:law.
Q 1 on cacmpl under Scc. ,B&P C for this mason
Owner Dere _
WORKER'S COMPENSATION DECLARATION
1 hmeby affirm under penalty of perjury arc of the following declarations:
Q I have and will mainuin a Ccrdfiam of Consent m self-insum fa Workers Compen-
u(ion,as prolmod for by Secdam 3700 of the labor Code,far The performance of The
work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,n requimd by Schon
f the lanor Code,for the performance of the work for which this permit Is issued.
My Warkar' °�pensxfi �wua ce exam and Policy num r.:
Cartier: ! PolicyNa.:
CERTIFICATE OF EX P ION FROM WORKERS'
COMPENSA ON INSURANCE
or less.) mre
(This e ma cd not he completed ifthc permit is far one hundred dollars 1$100)
1 em ifv mal in me life...of the work for which this Permit is issued.I shall not
employ anyperson in any manner sof as in become subject o The Workers ComPe,uation
Laws of Caltrnmia Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cerlfcam of Exemption,you should
become subject m the Worker's Compensation provisions of the Lahr Code,yaw muse
.JO foMwith comply with such provisions or Nis Permit shall M deemed mvokcd.
z Z) CONSTRUCTION LENDING AGENCY
f~ Ihereby affirm out there iso construction lendingegcncy,for me miesmamca
a the work for which this pereit is ismad(Sec.3097,Civ.C.)
0 lander'a Name
:D z lender,Address
O Q 1 ttnee that 1 haw mad this City
an coup and sum that and
above information misting u /
Is�0 F cored I agree m comply with all city and county oNi,wweo and sum laws relating to 5/
(]V 11Wwngco„oned propend forcnysumotlaempremnutises of this city mentor upon me
ahovmme.jadZ CnU Cos for"parts npurposes
n�F.r y (We)agree m vw,indemnify d lump harmless Om City of Cupertino against
fq Iiabili0u.juaca 0 8 I.fthiis which they in any way accmc against old City
V z in corstequcncc of 8 ung of this it,
APPLICANT UN ER ANDS AN ILL COMPLY WITH ALL NON-POINT Issued b
C
solrltcex c n � '�C��' � �e 05 Y Date
Signamrecf Applicam/Conuacmr Data Re-roofs
HAZARDOUS MATERIALS SCLOSURE Type of Roof
Will the applicant or fumm building Occupant store or harWlc hsonk ws material
C"deancd by The Cupertino Municipal Codc.Claim,9.12,and Oc Health and Safety
Code,Section]5532(.)?
QYa, Na All roofs shall be inspected prior to any roofing material being installed.
Will the. ream or future bundle mm ant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
w a p y 'pment or Marra which g p
Dishanrdnus air conumimnts u,mrncd by the Bay Area Air l'juality ManaScment all new materials for inspection.
DiWicl7 ,
Ycs
I have mad me hon ousmamrials reyuimmcnu under Chapter 6.95ofthe Caliror-
mi.Halth&Sdoycoteaseetions Sf15.2533m 2553e.lundcftifthe Wilding
Jots ret core Ir'h a tenant. at it
6 my msprodahty m ruddy the occupant or me
mquimmcm hic m u m erct m is uance car.CorOficam of Signature of Applicant Date
Occupemy.
C
Owner ur.umoriud agent 4 Dom All roof coverings to be Class "B"or better
Community Development
k 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
-2"57 //• 650.ZQ06.2_
OWNER'S NAME: r%?h/cs .2e PHONE # SOS �j(o 3$3
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Si ature Date
CITY OF CUPERTINO
FURNACE/AC o S, 0a �-
UPEkTINO PERMIT APPLICATION FORM
APN # � , � 03 Dat /
Building Address:�
�A257 I1.�VbZ �
Owner' are: Phone#:
s "3
9 !0 3.x`
C tor: / Phone: icense#:
.4d -
Contact: / Phone: Cupertino Business License #:
Building Permit Info: G
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
Residential �b Commercial ❑
For Residential Installations:
Attic ❑ 1" floor El2"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 Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
13'v 3
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BRENIA.IRHAN A/C Units <= 10, 000 cfin 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 Bldr,Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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