03120109 t CITY OF CUPERTINO
BUILDING DIVISION . PERMIT CONTRACTOR INF()1]2MATION r
4
auiLDlNc nooness: A PERFECT CLIMATE PERMIT ND 03120109
OWNER'S NAME: PERMITISSUEDATE
ONE: SANITARY NO. CONTROL NO.
( 863 -9545 408)
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 0
ou o LICENSED CONTRACTOR'S DECLARATION .Job Description
?��ou I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing 7 ptl0n
with Section? o t' a 3 of the Business ro inns DJ a license is
in mumrce fin e EPLACE FURNACE & ADD A/C r',V q LE®
z LicenIf Lu.M ,VI""!
O Dam Cumrazmr
?EARCHITECTS DECLARMFON
Y C 1 understand my plans shall he used as public records
i:0 Licensed Prnfcuianei
JAN 0 2 2004
R OotNE in exempt
DECLARATION
4 a y I hereby strata t0rm thm I . exempt from the Contractor's Co e:Any c Law fur the
p o which re massa.(canton ca L5.Business and Professions Code:Any city(it county B 1'' DIN
3:0
$
which its requires a protan re dnnst...1,alter,improv..demolish.nr repair any strumum V • • 'Y
aZ j,
poor to issuance.also requires the applicant for such Permit o file a signed statement
££x`e thathcislicensedparamouuotheProvisionsOftheCmure,hr'sLicenseLew(Chapter9 Sq. Ft, Floor Area Valuation
Yr" (commencing with Section 700h of Division 3 of the Business and Professions Code)or
y`<� Nat he is enempl therefrom and the basis for the alleged.xemptloo.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 y1�&iUIL5t9Cr0 0 Occupancy not mom than five hundred dollars($50r. P y'I�Pe
❑I,u owner of Ne property,or my employees,with wage es thak iiia compensation,
will do the work,and On a"car.is at intended or offered for sale(Sec.7094,Business
and Professions,Code:The COM.elors License Law does not apply to an owner of Required Inspections
property who buildsmimproven Human,and who door such work himself or through his
Own employees,provided that such improvements arc not intended connoted for sale.If,
however,the building or improvement is sold within one year of compledon,one owner.
builder will have the burden of proving Nat he did not Wild or improve for purpose of
selcJ.
❑1,as owner of thr prolan,am exclusively contracting with licensed contractors to
constmet the project(Sec.7094,Business and Profession Code:)The Contractor's Li-
cense Law does not apply toanOwner af property who builds or improves daemon,and
who contracts for such projects with a contractor(s)licensed pursuant in the Contractor's
Lieenu law.
❑I am oxempr under Sec. B&P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION -'
1 hereby affirm under penalty of perjury arc of rhe following declarations: -
1and will maintain a Cenifiare IConsent to self-insure for Workefs Campen.
satin ,u provided for by Section 3700 of one labor Code,for the asof....of the
or for which this permit is issued.
have and will maintain Worker's Compensation insurance,as required by Section
the lab
or Code,for the performance critic work for which Nis rmi'uppoied.
My War r' n pe a'on Imum ce artier end Policy a r
Cartier: - olicy Na.:
C R I 7E OF EKE ON FROM WORAERS'
COMPENSAT IN INSURANCE .
(Thu section need not he completed if the Permit is for one hundred dollars I$Bill
a,loss.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become sobjecuo the Workeri Compensation
Laws of Califmnla.Dat.
APPliant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Campensotian provisions of the Labor Code,you most -
., forthwith comply with Such Provisions or this permit shall be deemed revoked.
z o CONSTRUCTION LENDING AGENCY
[-t 14 I hereby affirm that dere is a construction lending agency for the performance of -
C'> the work for which this permit is land(Sec.3097,Civ.C.)
W Q Under'3 Name
jz Lender's Address
V F. I ttne/a )
N ave read thirty ad coon and duan that the shove information is
V.
F. agree i ply hem ani city d7m repM$ordinances and awm laws relating I.
e
0O building ti ,and forebyachorbarepresenutivrs of Nis city tocnurupnn dm
VI ed roperd for inspection whichpurposes.
e e to rove,indemnify and keep humless the City of Cupcnina against
uFa rA meats,cosh and exposes which may in any way accme against said City
U z cannee of the granting 0 Lhi omit.
"+ T UNDER ANDS D WILL COMPLY WIT ALL NO -POINT Issued by: Date
EGULA S. r'/ sL
Y Re-roofs
S' natum mApp a Co motor Dam
ARDOUS TERIALS DISCLOSURE Type of Roof .
Wil a 'ant ar Future buffing ace.ptaluemiandi.limandous material
as d.11. y the Cupertino Municipal.Cade,Chapter 9.12,and On Hoak o and Safety
ad action 25532(.)?0 Yds o All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant uturc b L am use equipment orMeadevices which P g
h haxardnus air cont man J y t ay Arca Air Quality Mana&emem all new materials for inspection.
isoictP P
❑Yes
I have mad the he use amsrcy tomenta under Chapmr6.95afthcCalifor-
n4Hcalth&SxfetyC , c' ns 05,2553 and2553 dermadthlifthe building
acs not cumad,h a a ,thmit is my spun' it,to ad ly the nets antofam
require memawla- n etpdormi. to acentric arOcdnnan Signature of Applicant Date
o r ihori agent All roof coverings to be Class"B" or better
CITY OF CUPERTINO
_ o 6
. � 2
o«t FURNACE/AC 3� �
OF
CUPERTINO PERMIT APPLICATION FORM
APN # a� Date'
Building Address:
Owner's Name: . p o q ^
Con ctor: Phone: License#: !�
Co lace Phon : I , ` Cupertino Business License #:
I �-t
Buildingercmt Info:
Bldg ❑ Elect Plumb ❑ Mech
Job llescription: ' �p�C,C,e ,� ��� ./1 A
Residential Commercial ❑ l
For Residential In�a Ilations:
Attic ❑ 1" floor LJ 2"d floor ❑
Adhere to min set back requirement❑
• For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost roj Type of o struction: Occupancy group:
ac
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A tc b Fee ID Fee Descri tion Fee Group
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
!BLIC
RMITFEE Elec Permit Issuance ELECTRICAL
ERMITFEE Mech Permit Issuance MECHANICAL
RMITFEE PlumbingPermit Issue PLUMBING
RMFEE BldgPermit Fees BUILDING
ANCHK Plan Check Fee BUILDING
Business License 4 BUILDING