05010095 CrfY OF CUPERTtIVo T11TRA
BUILDING DIVISION PERMICOCTORAINFORMATION.,-,i
au1LDINGADDRFSS: A PERFECT MCLIMATE PERMIT NIO5010095
0848 ,NQRTT4RT4()RR go
OWNER'S NAME: PERMIT ISSUE DATE
CELESTE M GENTRY 10570 S DEANZA BLVD 01/18/200S
ONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION C7 O O O
� F❑ I Hereby arum m.,1 am licensed trader vmw;aipm of chapter 9(emm"cing Job Description
<W with Seen..700(f.f Division 3 of NC DusinOxsand Professions Codc,aad my license is
j�_ in full amar .�� Y REPLACE FURNACE & ADD A/C
License CI Lac.0
o I-a Dam Cum rot
gnI ARCHDE DECA ON -�
f i u 1 understand my plans shall be used as iae Cut& / P fl p
ctrl' Licensed Professional I/
g OWNER-BUILDER DECLARATION CJ��
s f 1 hereby alron that I am exempt from the Contractor's License Law for the
O O following reason.(Section 7031.5.Business and Profemimts Code:Any city Or county
5 m which rewires a pe.it 1.ennmruct,alter,impure,dcmmlt+h.Or repair any structure $5600
-Z In Prior o its iasuanee.also requires the applicant forsdch permit to 11c.umodmmemenl
< that he is licensed pusuonuobepmvisioruoftoContractors License Law(Chapter 9 Sq. Ft. FI orArea�i Valuation
LIZ-$ (commencing with Section 7000)of Division 7 of the Business and Pmfessiom Cndc)ser
_
that he is exempt Nemfmm and the basis.for the alleged exemption.Any violation of /C),
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of 3']AP1.3�O.l 0 Occupancy Type
nor mare man five hundred dollars(S!00).
P Y YP
0 1,as owner or the property.or my employees with wages as their salt compensation, Ir�,
will do de work,and the swctuoe is not imeackd oroRered forsalc(Sec.70414,Besiness i
and Professions Code:The Canlnmrr.License Law does not apply to an owner of Required Inspections .
property who builds or improves Hereon,and who doessuch work himself orthrough his
own.red.yees,provided that such improvements arc net intended or.Raed for sale.If.
however,me building or improvement is Cold within one year of completion,One owner.
builder will hate the burden of.roving that k dice not build or improve for purpose of
sal'.).
❑1.as Owner of the proWny,am exclusively contracting with licensed contractors to
Construct the project(Sec.70414.Business and Professions Code:)The Contractor's La.
cane law does nor apply to an Owner of property who Wilds or improves Hemon,and
who contracts for such projects with a eonu ctor(s)licensed pursuant to the Contractor's
Lies.Law.
❑1 am exempt under Sec. .B d:P C far His reazon
Own" Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury One Of the following declarations:
I have and will maintain a Cenafia¢of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the labor Code,for the performance of dm
work for which this loan is issaed.
have and will maintain Workers Compensation Insurance,as myuired by SCCLmn
700 of the labor Code,far the Performance of the work for which His permit is issued.
My Worker m emaimn lnsu tee canacra rI Policy nu beram:
Carries Policy No.:2 g m!9 _egg
CERTIFICATEOFE EMPTIONFROMWORKERS'
COMPEN ATION INSURANCE
((Tis section reed not kcomFlcwd lube permit u(Drone hundred dollars(5100)
or loss.)
I sonify that in the pe,furmance of He work for which His Permit in;issoed,I shall not
employ any permn in any manner Co u an become subject to Ik WorkW Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If.after making this Cenifcate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
� ,Z forthwith comply withsuch provisions or INS permit shall W dccmed revoked.
z'O CONSTRUCTION LENDING AGENCY
1 kmby affirm that then is a cuns,mcrion lending agency for He performance of
5> be work for which this permit is issued(Sot.3M,Civ.C.)
4 0 Lenders Name
z Lender's Addm..
JO 1 certify dust 1 have read has application and atom the,He aneve mr.mroiun is
y F correct.l agree,o comply with all city and county ordinances and state laws relalang to
V building conswnaon,and hereby aolmoine Mima,mslocS of this City w corer upon me '
Y a show-mcntionod nmpcnt for ndcx,p ra s purposes.
(We)agree ld save,indemnify a arca
p harmless the City or Cupenstsaid by
N liabilities.Judgmenu,coals and expertses hmay in any way atmos gainslsaid City
;Jz in��oing Of thispe .AgNDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Dale
S
Re-roofs
Signature of ApplicanUCanmct" DateHAZARDOUS MATERIALS ISCLOSURE Type of Roof
Will the applicant or future building occupant atore or handle harsrdous material
as de acd by Ik Cula nia-Municipal Cotle.Chapmr 9.13,and de Health and Safety
otic.Section 15531(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will due. Beans nr mlure bmlain oats an,sere a If a roof is installed without first obtaining an ins ec[ion,I agree to remove
PP g P 4vipmem or devices which g P
h M1arardnus air Come-nanls ss Jcfincd by the Bay Area Air Quality Managcmcnt all new materials for inspection.
iatricl?
C]Yes fu
I have read He hanrdowsm lata myuimmcnts under Chapmr QYS of the Califor--
niaHealth6S etyCede,Sections 25 5,1557}and 255}4.1 undersuodmnifthc Wilding
des not cane dy ha moot that i my responsibility to oddly the aeupan,Of He
myuimrncnts bleb bemet 7,to uane ofd Cudfcam of Occu ancy.
I r , $,D5 Signature of Applicant Date
Owner or authorized open. o Dam All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
e Dom! • D
OWNER'S NAME: Ce,& PHONE ,P
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 c
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
c Tile
Owner/Contractor Si ature Date
CITY OF CUPERTINO
1' -J!Llys ACE/AC
UPERTINO PERMIT APPLICATION FORM
APN # >' / Date:
1 • i8 a
Building Address: /
Owner's N• Phone#:
Cont r: Phone License #:
d � 5 7J,31,5?
Contact: Phone: Cupertino Business License #:
ee
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mechl-�
Job Des tin:
e
Residential( Commercial ❑
For Residential Installations:
Attic ❑ 151 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 ❑
New installation Planning Approval Required ❑
Cost of P&roj ct: Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacement�
Qty. if
AppKc'4hle Fee ID Fee Description Fee Group
BENERGY nergy 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
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