03090146 +CITY OF CUPERTINO -'
BUILDING DIVISION PERMIT CONTRA.CTI?RXNIGRMt�T7QN
jl BUILDINGADDRESS: ANPERFECT CLIMATE PERMITND03090146
OWNER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
NE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILpIN0 PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o
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LICENSED CONTRd under
DECLARATION
1 I hereby affirm that l am licensed under provisions of Chapter 9(commencing lob Description
with ScorecraX1U)nf Division Sof Ne Business antl Pmfcssinre de.antl cry license is
or in full force and 01, REOLACE FURNACE & ADD A/C
Z LicenseC s Lick
� Dale
Carl reclot
A HITECCSDECLARATI
E 1 u I and rsund my plans shall be used as public records
e G y Licensed Pmfcssianel
OWNER-BUILDER DECLARATION
`v a 8 1 hereby affirm that I am exempt from the Contractor's License Law for the
20 following mason.(section 71131.5,Business and Profession,Code:Any city or county
5:(L which requires a permit to construct,alter,improve,demolish,or repair any structure
-iy poor to its isionva,alsu requires the applicantforauch ohnnotm rile a signediamemenl
esa that he is licensed pursuant it)the pravisions(If the Contractor's Lincom Law(Chapter 9 Sq. Ft. Floor Area - Valuation
2H (commencing with Section 7000)of Division 3 of the B nations and Professions Cost.)ur
i W§ that he is exempt therefrom and Use basis for the alleged exemption.Any violation of 3 1644017 . 00
Section 7031.5 by any applicant for a Permit subjects the applicanuo a civil lethally of .APN Number indnithanFvehundred endars(S500). - - - - - -- - OccupancgType- . .
❑1,as owner of the paerest,or my employees with wages as their sole compensation,
will do Ne work,and thestmeture isnot intended proffered for mic(See.70W,Business _
and Professions Code:The Comunor's License Law does not apply to an owner of Ct10n5
property who builds or improves thereon,and who doessuch work himselfor through his 303 - ROUGH M CHANT AL
own employees,provided that such improvements am not intended ororcered for sale.If, 304 — ROUGH ELECTRICAL
however,the building or improvement is sold within one year of emaplmime,the Owner-
builder will have the burden of proving that he did not build or improve for purpose of 505 - FINAL ELECTRICAL
I.I.J. 507 - FINAL PLUMBING` -
I,as owner of the Sec.property,am exclusively contesting with licensed caeamors m
centumthe
es not apply
to an wnerof and Professions code:)The Contraaor's Li-and, 508 — FINAL MECHANI f
cense Law docs not apply loan owner of property who builds or improves flancon.Conbec and !!t
who contracts for such projects with a contractor(s)licensed pursuant m dm Cnnvactor's
License Law.
[D exFEB
I am empt antler S.C.Sec. ,B&P C far his reason 7 2
004 Owner Dae
WORKER'S COMPENSATION DECLARATION ��a/
I hereby affirm under penalty of perjury one of the followinj decimations: - U�,A//�
1 have and will maintain a Ccnificae of Consent to self-insum for Worker's Comped- /'r■G
lion.as provided for by Section 37W of the Labor Code,for the perfmmance,of the
rk for which this Permit is issued,Ihave and will maintain Worker's Compensation Insurance,as required by Section
W of the Labor Code,far Nc performance of the work far which this permit is issued.
Worker' pensati Insumt Cartier and Policy nurtier. l�.,(�Policy No.: ram:�� y
CERTIFI ATE OFEX6MPr10N FROM WORKERS' O
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars(law)
or less.)
I cuddly Unit in the perfmmane.of the weak for which this permit is issued,I shall not
employ any person in any mannersn sem become subject to the Workers'Compensallon
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compauation provisions Of the labor Cold,you must
Oforthwith comply with such provisions or this permit shall M deemed revoked.
Z N CONSTRUCTION LENDING AGENCY
i hereby afT m thaI Ihue is a construction lending agency for he performance of
3i > but work for which this permit is issued(Sec,3097,Co.C.)
y Q Lender's Name
7 z Lender's Addooas -
J C 1 comfy Nal 1 have read this application and suite Una Ne above information is
HCortes.1 agree to comply with all city and county ordinances and state laws relating to
JU building Conswction,and hereby authanae representatives of Nis city to enter upon the
W above-.(WOlght printery fmiruidify alevo,purpose.a
14 (We)agree to save,indemnify end keep can the City o c aged n gainer ppp
h inconsequence fthecosts end ex nsesw ' ma in any wayeceme age' acid City /
:)7 in consequence of the grami his i /
r� APPLICANT UNDER N A LL C 1PLY WIT L PO T Issued by: Date
SOU E EGU NS,
Re-roofs
Signature ofApplican esDOlor Da
ZARUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle havalcous material
as defined by the Cupenino Mu icipaI Codc,Chapter 9.12,and the Health and Safety
Codc,Scchon25532(a)? /
Eyes All roofs shall be inspected prior to any roofing material being installed.
Will the apPlica I are Jing occupant use cyuipmenl or Devices which If a roof is installed without first obtaining an inspection,I agree to remove
7iL haardous ar coummadu Nedby the Bay Area Air Quality Managmcnl all new materials for inspection.
YesNoI have read the harallousm rials myuirc n unJcrChepmr6.95O(thcCalifm-
Health&Sa(cryCotic,Suuo SW5,2553534.1 undersand hslifthc building
s nal cumcn0y have a¢ tit is spo ieilim c Occup t of theuircmcnk aort cc aCcmf E� c/ Signature of ApplicantDate
nerermxmhmonc gem ;,e All roof coverings to be Class "B"or better
CITY OF CUPERTINO
FURNACE/AC /
CUPERuvO PERMIT APPLICATION FORM
APN# � 1 j I I� Dater
Building Address: `R
Owner's ]Same: I Phone#:
oadn Wow WI)
Co tractor: Phone License#:
0 I--Gly a ,31
Cont ct• - Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect 14 Plumb ❑ Mech
Job Descriptiore�_eP 1G['JL�VY✓LC� Q G l 0.S�Cj �-
Residential Commercial ❑
For Re idential Installations:
Attic U 1"floor ❑ 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural talcs) ❑
Structural Calculations required for new installation ❑
New installatio -Plannin Approval Required
Cost of Pro' ct: Type of Construction: Occupancy grou
S 0
Strapped atform ❑ , Bon ed ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacemenpp "�)
Qty. if
A W4 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 cfm MECHANICAL
BREMRECEPT Rec tl, Switch &Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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