03050098 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORIN'�UTi VIATIO. o-
BUILDING ADDRESS: A PERFECT CLIMATE PERMITNO.030yy��5,,0098
Q7119 PAR THREE DR
• GWNER'$NAME: 10570 S DEANZA BLVD PERMIT��b/ 21/2003
IM HEYBOER
NE' (4 0 8) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0
JOO LICENSED COIqTRACIDR'S DECLARATION Job Description
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing P
with Soudan 7000)ofDivition 3 of the Business and Profeudoa Coda,and my license is
+'1=Z Li 0 imfall f" a1.'"�°on
,o Lieu a INSTALL FURNACE & A/C
Datem`CI ARCHnECTS
DECLARATION
1 un&.ad my plans"I he used as public records
Licensed Professional MAY 3 0 2003
OWNER-BUILDER DECLARATION
f 1 herehy affirm that 1 em exempt from the Contneors License law for the
D D following moon.(Section 7031.5,Business and Rofcssinns Cade:Any city or county 1 L�
which requires a permit m construct,alma improve,demolish,or repair my structure BUILDING
Prior In its issuance.aim requires the applies.,farsech permit be III easigned summer,
< Net he is licensed pursuant in the provisimu of the Contractors L'uxnm Law(Citrte $
mr 9 Sq. Ft.Floor Area 6131 a�1On
3
(commencing with Section 7")x1 Division 3 of the Businessattd Professions Code)or
V
that b as exempt therefrom and the thesis for the alleged assumption.Any violation of
Section 7031.5 by any applicant fora permit subjects Ne applicant be a civil penalty of 3 SBN D OWler 0 0 Occupancy Type
oat mom than five hundred dollar(S500).
❑h asown¢of the property,army employees with wage u their tele compemation.
will do tW wart,and Nesuunun head intended oroRered fmula(Sec.709,Business
and Professions Code:Th.Cmdrumrs Liam Law dao set apply to an ownec of 3 0 3 - ROUGH M CHAN CAL ns
property who builds or Improver Hereon,and who does such work himself or INough his
own employms,provided that such Improvements art not intended mo0ered for sale,If. 304 — ROUGH ELECTRICAL
however.the building or Improvement 4mld within one year of amp mon.the owner.
builder will have Ne burden of proving that M did not Wild or improve for purpose of 505 - FINAL ELECTRICAL
i1e')' 507 - FINAL PLUMBING
1,a oweer of the(Sec.
am exclusively cantractimg wtd licensed urecteon e
construct La Ne project(Sec.ANO,Business and property
who ns Code:) Conuacter,Li�red 508 — FINAL MECHANICAL
whoa law dose not applyje ts owner of property who Wilds or improv¢thereon,and
who use Lacca for such projects with a cantranor(s)licensed punanl a de ConusetaM1
License
IJW.
❑lam exempt under Sec .Bd PC for this maven
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penury of perjury arc of the fallowing declarations:
I have and will maintain a Certificate of Consent to self-boom for Wor aces Camper.
ration,as provided fm by Section 37011 of the Later Code,far the lumbarmance of the
k for which this Permit u issued.
1 bare uW will maintain Worker's Compeo sash,Insurance,u required by Section
3 of the labor Code,for Ne performance of the work for which this permit is issued.
My War e Co. ensNon Ins reace carrier and Policy nuum,�b�s/�alspf(�(!�
Carrie, Polity No.:J�1�0��.d,;
CERTIFICATE OF Rxis FDON FROM WORKERS'
COMPENSATION INSURANCE
(This=dm need not bcomplcud ifout permit Is foo e,hundreddollars(31(0)
carless.)
I certify Net In In.porformseec of Ne work far which Nis Permit u issued.I shall not
emn
ployany tannin yncr ave t4wPoatTi> bjecttode Workers Compewdm
laws of C&lifoml& esmatterer
NOTICE
OTI
NOTICETO APeLdMW.IL afros making this Ccsiinau of Exemption.you should
become subject a it Worh r os orthis
Compensation permit
provisions of the labor Code,you must
Oforthwith comply with such previsions or Nis permit shall b deemed revoked.
z ayN. CONSTRUCTION LENDING AGENCY
'rr Iborehy.drum Net there isaconstruction lending agency for Nc performance of
a the..,it for which ads permit Is issued(See.3097,Cl,Q
dLeadcis Name
.7 z Lumber's AM ..
U Q 1 certify Net 1 have read this application and sum Nu the&hove information Is
Y.E Correa I agree to comply with all city and county orhmamvs and state laws mlating to
O Wilding construction.and bercby authodm representatives of this city In ants draw the
[rd abova-mentioned property for inspection purposes
y (Wu)agree b save,indemnify and kcep harmless the City of Cupertino against l
rat Iiabilitia,judgments,costs and expanses;which may in any way accrue against said City
V 7 in consequence of the granting of this Permit.
r•+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApPlicaATDO u
Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII IW suppliant orlmurc Wilding eccupanutore or handle hauNous material
as defined by the CuNninok'icil Code.Charter 9.13,aM tie Health and SafetyANkMe,Soednm zss3z(a>? All roofs shall be inspected prior to any roofing material being installed.
❑Wthrplicant o building accurate sew equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air canumX.u. MudbytbBayArtaAirQualityManagement all new materials for inspection.
❑Ihavc read Nt hersaurcquim=nuunderCMpw,6.95ofIWCalifor-
riaHalthgs5afel hoc, 'an255o5,15533and 155th.lundcrsund dw if Ne Wilding
Jaes not curnn hart ret,Nu it u my rcsponsihility b notify the accuran(of Nc
roqulreman chs pdorwissuanccor.conrm., g`trp Signature of Applicant Date
owneafa ret 7�l oaeI All roof coverings to be Class"B"or better
�.. CITY OF CUPERTINO
c Fi'i�;it . PERMIT APPLICATION FORM
APN # D�O LN Date:
Building Addr
(� : r�nrZ� fir.
OT's Name• Poe
"TiM Re - O S
�ontraev r: I License 131 C
ja
Con act:& Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: �S,�
'TL1 t� Qj (�
Residential , fr Commercial El
For Residential Installations:
Attic ❑ I' floor ❑ 2nd 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 Planning royal Required
C of Pr ' ctrl �' Type of Constructiz� _' Occupancy group:
i
Stripped On Platform Bonded Sq.Ft. Floor Ared.
New Location ❑ Replacement ❑
Qty.if
Ap i a le Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 ctm MECHANICAL
BREMRECEPT Reept], 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
BPLANCI-IK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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