05020124 CITY OF CUPERTINO c'�` �•` aF "'Z•� " ATION sPERMIT BUILDING DrvlstoN
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9u1LDING ADDRESS: A PERFECT CLIMATE PERMIT"D05020124
OW NER'S NAME: PERMIT ISSUE DATE
DINGER
6 ONE: SANITARY NO. CONTROL NO.
408 861-
ARCHITECTfENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOp LICENSED CONTRACTOR'S DECLARATION /its O O O
C 1 hereby affirm Nal I un littered under provision of Chapter 9(commencing Job Description
Ziy with Section 7")of Division 3 ofthg c Business and professions Code.and my licensee /
a
in full force and effect.
5qi
Li,..CW. ' REPLACE FURNACE
Z;:, Cktractor v
ARCHITECTS DE LLA ndr ION �I�Z
I understand u
nd my plans dull he seaz m
d public records
NIP
10� Liccnud Pmfcuional y
g OWNER-BUILDER DECLARATION ryvH ?�0
.� y 1 herehy alum that 1 am exempt from the Conhamors License Law for the S
po following region.(Section7In L5.Business and Pmfcssiou Cale:Any city or county �
is which requires a permit to consumer,alter,improve,demolish,or repair any structure
Fieprior to its issuawe.alsu requires dteapplicant for such permit to file is signed statement
s thin he islicenudpursuant tothe provision ofthe ContracmrsLlanuLaw(Chapter 9 Sq.Ft. Floor Area U(� {I,Q� Valuation
z�rs (commencing with Section 7000)of Division 3 of He Business and Professors Cale)or l�
y $ Nat W is exempt therefrom and the basis for the alleged exemption.Any violation of
section
moat than five�dreddeltars(SSt for a W sI subjects Ne epplkantmacivil penalty of 3 61PAbet00 Occupancy Type
I,uawnerofthe pmpeny,amyeunntendes orHwagnuHevulc 04,1. uimeas
will dou tewart.andth The Compactor's
intendedaotQe 1n forsale7041,Business
and Profession Cade:The C sftwo.License law such
cot apply m an owner of Required Inspections
com reproperty who builds ori d On,such
Hereon.and who does such wort Magellan Image.
awnemployes,providedthinsuchim is sold itartnot i,.MWmpeered fault Ir.
builder.Hebuildingncimpmwmeini[hold withinone Wild
of completion,theowner.
of
builder will Gave He burden of proving Has he did not Wild w improv for purpose of
sok.).
❑1,as owner of the propcny,am exclusively contracting with licensed contractors to
contract He pmjecL(Sec.7614,Business and Profession Code:)The Contractors Li
cense Law dotes not apply in an owner of property who Wilds or improve thereon.and
who consracta for such projects with a cormacmr(s)licensed pursuant m the Contractor[
LKenerlaw.
0 1 sum exempt under Sec. .B&P C for His reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of He following declarations:
41 1 haw and will maintain a Certificate of Consent to self-insure for Workers Counter.
s i as provided for by Section 3700 of the Labor Code,for He performance of the
work for which this permit is issued.
1 have and will m+inuin Workers Compensating Inurana,as required by Secuon
3700 of the LaWf Code,for the path make ofthe work for which this permit is issued.
My Work c, Fon ensation I ran=camer and Policy number am: ^
Carrier. _
CERDIeTCATE OF E% PTION FROM WORKERS
COMPENSATION INSURANCE
(ITissection need not W canPleted if the Permit is forone hundred dollars(SIM)
or lust
1 certify that in He performance of the work for which this permit is issued.I shall not
employ any person in any manner as to become subject o the Worker Compensa0an
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of E`emption,you should
bounce subject to the Workers Corepcnmdon previsions of she Labor Cade,you mug
.,O forthwith comply with Such provisions or this permit shall W deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
F-m 41 hereby affirm that there is.construction lending agcnry for the performance of
C'� the work for which this permit is issued(Sec.3W7,Civ.C.)
Uj Q Lcmlcr's Name
a z Lender's Address
U 0 1 certify that 1 haw read His application and sum that He shove information u
IT. Croat.I Agra In comply with all city and county pNinuces and sate laws relating to
0 building eonswction,and hereby authodm repmsenuuves of this city to enter upon the
�+a abovcuns Judgmoned property(aroexpenses purposwhich may
(We)agree to saw,indcmrfy and kap harmless the City of Cupcnino against
H Z
liabilities,cnuence of the
expenses which may in any way stere against said City
UZ in consequence of Ne graining of His permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POI M Issued by: Date
ERE TIONS.
f 6 Re-roofs
Signgu of ApplicmUCotn.acmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will He applicant or future building paupamstorc orhandle banNous material
as defined by the Cupertino Municipal Cole.Chapter 9.13.and lite HW H and Safety
'AaLcoce.SectioYca Nun 35532(.)? 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 He applicant or future Wilding occupant rex equipment or devices which p
mit haeardous air contaminants u dcfincd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea
I have real the hamwdous materials requirements under Chapter 6.95 of the Califon
nice Beg"&Safety Coo.Sectiau 25515.35533"25534.1 undersand that if the Wilding
Jas not curmngy b.m a tenant Nat it u y reaporibility m noulY ale acupant of ale
men whhmusthe Ipriorm .mm..f.CmlhcareprOcap ey. Signature of Applicant Date
Ow
or i u limind agent D,te All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
a. Cupertino CA 95014
Telephone(408)777-3228
CRY OF Fax(408) 777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT# �
970_562, 012
Z o1 Z�
OWNER'S NAME: PHONE !t a257—�e'a
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
6d I 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
o �• /7 OS
Owner/Contractor Signature Date
CITY OF CUPERTINO
z
FURNACE/AC
CTY of O��/ ✓/�c�
IIUPERTINO PERMIT APPLICATION FORM - l
APN # Date:
Building Address: \
Owner's Name: \ Phone#:
Co trac Phone: License
Xin #:
1 �OP &/- s 7.Q3i6F
Contact: —T— Phone: Cupertino Business License #: -
Building Permit Info: -
Bldg ❑ . Elect Plumb ❑ Mech
Job Description:
/2c2—
Residential _ Coinmercial ❑ ____.__,_,_
For Residential Installations: ns
Attic ❑ 151 floor E32nd floor❑
dhere to min set back requirement❑
For Commercial Installations:
Replacement 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:
Bcn
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN fFurnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRFLAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMTTFEE Elec Pen-nit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING