03100172 CITY OF CUPERTINO
NTRCOI?kMATI0 �
BUILDING DlvlsloN PIRMIT ,
sBUILDINGADDRESS: A PERFECT CLIMATE PERMIrND03100172
22374 PALM AV
OWNER'S NAME: 10570 S DEANZA 13LVD PERMIT ISSUE DATE
JOHN CHAU _____!0Z23/2003
IFNE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
100
LICENSEDmthatCONTRACnderp DECLARATION
m❑ 1 hereby affirm That I am licensed under provisions of Chapter 9(commencing Job Descripti(M_ftmr
I
�yW with Section]OBD Division Sof Be Business and Professions Cn p,and my license is -
in ran m0"erase fie •REPLACE FURNACE ��C®
_ Liccnm s Contract., '
p Dao Contractorn
+H',y
—ARCHITECT'S OECLARAT da MQpR 1 t) 2004
I,u 1 understand my plans shell be used as puhlie rccoms
°u�(
Licensed Professional B(/ p D11V
7+ps OWNER-BUILDER DECLARATION '/`r
2 n O 1 botchy.(Sera that 1 ora eat,mpt from the Contractor's o License Lew for the
p O following massa.Permit
i ]1111.5,Business and improve,
de Professions Code:Any city m county
e m which requires a FcmAit m construct eller,imprnvc,dcmnlish,or repair any abunvm
$2133
°zy poor In its issuance.also requires the applicant for such permit o rile a signed stammer[
:Z¢ that he is licensedpurmannolheprovisionsofthcContractor'sLicenselaw(Chapter9 Sq.Ft. Floor Area Valuation
ZFp (commencing with Section 7WO)of Division 3ofthe Busincsand Pmfessions,Code)or 35704064 . 00
Nat he is exempt therefrom And the basis for the alleged caemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APNNumber Occupancy Type
Outmamdeanrvahundmtldollars(s5D)). Pane Y YP
❑I,As owner of the property,or my employers with wages As their sole compensation,
will do Ne work,and One slructum is nut intended oroffered far sale(Sec.7W.Bulinus
said PmPessions Codc:The Contractors License Law does not apply to An Owner of Required Inspections
property who builds or umprovos Narcan,and who does such work himself or through his
own employees,provided that such improvements arc not imt,nded Or offered formic.If.
however,the building or improvement is sold within One year of completion,the owner.
builder will have the burden of proving that he did not build at improve for purpose or
.1.).
❑I,as owner of the property.am exdusively contracting with licensed contractors to
construct the pmject(Sec.7049.Business and Professions Code:)The Contractor's LL
come law docs not apply to an owner of progeny who builds or improve Neuron,and,
who contracts for such projects with a contractor(s)licensed pursuant 0 the Contractor's
License Law.
❑I Am exempt under Sec. ,B&P C far this reason
Owner Oam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent ml6insure for Worker's Compere
scion,m provided for by Section 7]00 of Ne labor Code.for the Performance of the
R�pgLjyo�lr"��lk for which thiA permit is issued.
RI Wove and will maimain Workels Compcnsetion Insurance,ss required by Section
f Ne Labor Code,for me performance Or the work far which this remail is issued.
rk is n ensatimn Imumnce Cartier end Policy number am:
Carrier: Poltoy No.: I i0I
CER FICA OFE MON MOM WORKERS'
COMPENS IONINSURANCE
(Thisaccifi n need not he completed if the permit Is(iron hundred dollar(5100)
or less.)
1 comfy that in the performance of the work for which this permit is issued.l shall nor
employ any person in any manner An ss he become subject to the Workers'Compensation -
Laws of Celifidumn.Data
Applicant
NOTICE TO APPLICANT:IL after making Nis Corpicarc of Exemption,you should
become mhjMI to one Workers Compensation provisions of the Labor Codc,you must
Oforthwith comply with such provisions or this Form i t shall he deemed mvnked.
Z h CONSfRUCrION LENDING AGENCY
I hereby affirm that there is a construction lending agency l or the performance of
li the work for which this permit is issued(Sec.3097,Civ.C.)
YQ Lendcea Name
z Lender's Address
C) I century that I have read this application and Adult,that the above information is
Fcorrect.1 agree to comply with all city and county ordinances and state laws reusing to
7 V building coniWction.and hereby amhoom tepresenuadvca of this city to enter upon the
NU above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
LO) liabulities.judgmcnis artaamici nus which may in anyway accmt,against said City
J 7 inconsequenecoft grant' o t permit ?ice/j
a� APPLICANT U E DS A WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG A 5.
9
1 Re-roofs
Sign of c UContmcm m
e b MATERIALS DISCLOSURE Type of Roof
WIII Applicant or applicaser fuuilding occupant store or handle haous material
As dermad by the Cupertino I G carol,Code,Chapter 9.12,and the Health and Safety
.S 25572(.)7 All roofs shall be inspected prior to any roofing material being installed.
Yes Nu
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant, fu building Occupant use equipment or devices which g
it hammous air cinnamon. ts defined by the Bay Arca Air Quality Management all new materials for inspection.
istrim7 .�
❑Yes
I have mad the hmamaus Aerials mquircomma under Chapter 6.95 of the Calif.,
nit Health&Safety Code,Sections 25505,25533 and 25534.1 understand mat if tht,building
docs not cumendy se-a mnanL th my rcspomihit ity w sadly the amcupenn of the
rces not emawh tbemet n issy nceofa CemOoam OI the mccy. Signature of Applicant Date
Owner ora razed agent ld arc All roof coverings to be Class "B"or better
CITY OF CUPERTINO
FURNACE/AC n 1 7 2.
CUPERTINO PERMIT APPLICATION FORM
APN# e3S-7
Date: �d a O
Building Adire s:
Owner's Name: P ne#:
CWW
Contractor: 1,k-0 AAt P 2(Q1 -919(1J__ L qV31S8
Contat: o : "'?cJ — Cupertino Business License#:
s
Building Permit Info:
Bldg ❑ Elect 11V Plumb ❑ Mech
Job Description: RCPT " (? yyy
Residential NL^ Commercial ❑
For Rep�ssidential I Ilations:
Attic LJ I"floor 2nd floor❑
• Adhere to min set back requirement 0
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Co of Pro'ect- -7 S— Type of Construction: Occupancy group:
a,i 3D , 14v 3 t,.sz
Strapped ❑ On Platform ❑ Bonded ElSq.Ft. Floor Area:
New Location ElRe laceme
Qtyof
Ap 1c4b Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIltHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT 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