05090162 CITY OF CUPERTINO * Igo #
BUILDING DIVISION PERMIT CLINTRACTOR�INFORMATION °
BUILDING ADDRESS: A PERFECT CLIMATE PERMITN005090162
028 NOVEMBER DR
OW NER'S NAME: PERMIT ISSUE DATE
RODNEY ZIMMERMAN 10570 S DEANZA B 09/23/2005
ONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITEC PENGINEER' BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
t00 LICENSED CONTRACTOR'S DECLARATION ^ ` `7 St`� r
f D C 1 Manby affirm Nat 1 am licensed under provisions of Chapter 9(commencing Job Deseriptibn a„-.Y,
_Zea with Section 7”)of Division 3 of NC Business and Professions Code,and my license is
m full rOa anderrea REPLACE FURNACE ,
j g Z- License Class Lic.9
c 0 Dau Contracmr 2005
F� ARCHITECTS
DECLARATION VV
11< I understated my plans shill W umJ u public retards
'WV
g u. Licensed Pnsfessiunel
a O 3
OWNER-BUILDER DECLARATION
iY 1 hereby affirm No,I am exempt from,he Contractors License law for,he
00 following mason.(Section 9031.5,Business and Profeadons Cc&:Any city or county
339 which requires a permit to construct.altar,improve,dcmnlish,or repair any structure $1993
_Zi prior to its issuance,also requires the applicant for such vorrah to file a signed f,ammcnt
0that he is limmad purstrant to the Provisions of the Contractor's License Law(Cluiptir 9 Sq.Ft.Floor Area Valuation
'� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Nes he H exempt tWmfram and the,basis for the alleged cxempdon.Any violation of
Secdon 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of Br Occupancy Type
hot mot,Dan Ove hundred dollen($500). P Y YP
I,uownerofshepmWayormyemployaawithwages stheirmiccumprnmion.
will do the warp and the swctme u notimmaded m Offered farsak(Sec.71161,Business
and Profession Cada:The Contractor's Liaise Law docs no,apply to an owner of Required Inspections
property who builds orimprowt demon,and who doessuch work himself or through his
Own employee,provided that such improvements as notinmMed oroRead for sale.If,
however,Ne building or improvement It said within au year of completion,the owner,
Wilder will have the burden of proving that W did an,Wild a improve for purpoa of
sale.
1.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70414.Business and Profwiou Cada:)The Contractor's Li.
cense law dors not apply to an owner of property who Wilds or improves Neuron,and
who contracts for each projects with a contracsnr(s)licensed pursuant as the Conautors
Lkvve Law.
❑I am axemp,under See. .B&P C fothis v
Owner Data
WO KER'g C NlSAT70N DECLARATION
1 Wally aQirm-214,11101
ncle airy of perjury ON of ON following dalantiou:
I hawaod will main aCertifieam of Consent self-insure for WorlomsCmnpen-
amion,u Provided for by Section 37th of the labor Code,for the Fmfonnana of Ne
work far which this permit is issued.
❑1 haw and will maintain Worker's Compensation Insurance,u required by Section
3700 of NC Later Code.for the peRorm rens,or the work for which this panni,is issued.
My Worke's Compensation Insurance carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('nds section recd Out becomplcied trust Permit isroronchundred dhilan(SIM)
er less.)
1 cadfy that in the perfconsoce of the work for which this permit is issued.I shell not
employ any person in any manner m oma bI'muo the Workeri Compensation
Laws of Cahromia.Dare y_;c0i2
APPlicam ��7
NOTICETO APPLIC ,a@r maki n Ccnifiesm of Exemption,you shoulJ
become tuhjas m the o is Comp tion provisions of the LaW,Cade,you muu
z forthwithminplywiOsudr pravi.4o r Nis permitihall W domed mvokW.
z O CONSTRUCTION LENDING AGENCY
PI hereby afrmm that them is a construction lending agency for the performance of
W > the work for which this permit is issued(Sec.3097,Civ.C.)
U]Q Lender's Name
Z)z Lenders Addmas
V Q I certify that 1 haw read this application and sou that the above information is
I6. F' carina I agree to comply with all city and county Ordinances and tum laws miming w
pU building construction.and hereby authorim mpmicnu,iws of this city to enter upon the
}W atevpdis.judgm poperty for inspection puryoms
M (We)agree to save,indemnify and keep harelev the City of Cupertino against
l,iZ incoisequim a of Occrauing of this expansion which may in anyway accrue against said City
fJ z A cPLICANTc of the Ranting of this permit.
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOPOINf Issued by: Date �^ 2 3-dd—
SOURCEREGULATI 5 (�
Signature of li V cmr D Re-roofs
N ARDOUS MA AIS DISCLOSURE Type of Roof
Will eapplihmurfmualm occupant store a hurdle havardous material
u de nod
by the Cupertino Muni ode,Chapter 9.11,and the Health and Safety
trues El Y.
zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ye Nu
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ha>ardous air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
Wict?
r]Yes O
I have mail the ha ardausmamrialsmquimments under Clammy 6.95 Oldie Califor-
niaeiHcalN&SafciyCodc,Sccdares 15505.25533 and 25536.1 unEcrsundd thatif the Wilding
donot currently haw a ame, u nthat it my mspansibility to notify the acuPant of due
myuimmcnu which most met Peoria issuaucc tufa Ccnifcau of Oce Signature of Applicant Date
Owner ar em Dag 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
UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
/o ✓ ie rJi? rD �6/d,-�
OWNER'S NAME: Ovti(,e- -e/MM6i?MAA( PHONE # 0�r 26-;Z �?,oZ C?e�
GENERAL CONTRACTOR: PE/!FF_CT CL IMA» 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
VW ass / Glazing
Heating PFRFEC r GG/FIAT
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
�` FURNACE/AC
CITY OF
CtBuildin?gAddress:
O PERMIT APPLICATION FORM
Date:
`h vs
Owner's Name: Phone #:
Contractor. License #:
f,rr(fAor CItmd7,e- 7-731T51
Contact: Cupertino Business License #:
AX 7-fi u.K G 014&Lr�S
Building Permit Info:
Bldg ❑ Elect )2 - Plumb Mech a
Job Description:
/ZEp�lG/d/G 94(AC
Residential A Commercial ❑
For Residential Installations:
Attic ❑ 151 floor ba 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Plan,;,, A---, Re uired ❑
Cost of Project: S Type of Construction: Occupancy group:
/993
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement D6
Qty. if
A licable Fee ID Fee Description Fee Grou
BENERGY EnLrgy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 16,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cflm MECHANICAL
BREMIZECEPT 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
,9r6 � . 7r