04040194 CITY OF CUPERTINO
BUILDING DIVISION PENT CONTr1TORINF®RMATION
.k-T-
aeU1LDING ADDRESS: A PERFECT CLIMATE PERMIT Nlb4'O4O194
10192 PARLETT PL
OWNER'S NAME: PERMIT ISSUE DATE
SOFYAN NUGROHO 10570 S DEANZA BLVD 04 /29/9,004
ONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO EO
PLUMB MFICHO
>✓op LICENSED CONTRACTOR'S DECLARATION JobDescri tion
1 hereby.from NvN
at 1 am Iiceunder provision of Chapter 9(commencing p
n� with Section 7000)of Division Jcrf she On as and Profusime,Code,and an,liccnc is
In mu farteaed "Z3 \S g— REPLACE FURNACE
5 Lbeenw Class .M
Z s- Dau L-1onuusor .
A DECLAR TION Ci I '
�i I undenund my plan Null be used u public records
3
.d Licensed Profession]
OWNER-BUILDER exempt
DECLARATION
z a 1 affirm on 1 I. eampt from the Contrlindomo License taw for the
OO fallowingreason.(Section 703 construct,
Buasinasandmp Profession Code:Any city or county
which requires a pcnnh re cure;t eL a@r.Improve,h permit t or repair any irmactustatement
82962
f inn priwmiuissuance.
purse requites lhovisionof far such permit Me a
�< IIIL heulianuN pursuant to the provision of the Conuvc,or's License law(Chapttt9 Sq.Ft. Floor Area Valuation
se (commcaing with Section 7000)of Division 3 of the Business and Professions Code)or _ Amy 7
$
that he is exempt therefrom and she basis for the alleged neoption.Any vioudon of I // "A fI ^
Section 7071.5 by any applicant for a permit aubjecu she applicant in a coil penalty.( C f - Occupancy Type
not mom Nan Ove hundred dollen(S50O. \
( I '
❑I.ns rortmpmpeny,mmyempiy wrhwgesasthehanlecampenastion' In\ I -....�
will do the work,end theima ure is nut intended in.Rimed far.toce.7We,Bmimm .I '`
and Profession Code:The Connctor's Limns law don not apply w an owner of // I 1 I I '�ReAITe Inspe 'ons !
property who buildaor improves deecon,andwhodouauch work himselfor through his U u U U
awn employees,providedre that such Improvements anot intended orortered for We.If.
however.Ne building or Improvement iswld within on you of compkdon,discounter.
builder will ban Oe burden of proving shut he did rut build or Improve for purpose of
sate.).
❑1.as owner of the property am exclusively contracting with licensed contncun in
construct the project(Sec.70.4,Business and Profession Code:)The Contractor't U.
echo law docs not apply w an crasser of property who builds or improves thereon.and,
who conran for such projects with a enuamor(N licensed pununt w the Contra toh
License La-
01 v.eaemp,under Sec .B k P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby Mm under penally,of perjury one of the following declaration:
I have and will maintain a Ceniftcete of0mucts w viPlosum for WorkcYa Compete
setion,as provided for by Settle.3700 of the labor Code,for the Performance of the
work fm which this permit is ivued.
❑T ban and will maimain Worker's Compensation Imran.,u requited by Section
3700 of the labor Code,for the performance of the wort for which this pent,is issued.
My Warkefs ComPenaatian Issuance�narriu'and Policy num
Cartier. Wl 3 A C _QvttT s.Qa .f(m
CERTIFICATE OF EXEMPTION FR MWORKERS
COMPENSATION INSUR CE
(This sxlian need not becompleted If the Permit isfaronchundrtddollan(SIM)
lass)
1 unify that in the performance of the work for which this Permit is issued.I shall not
employ any person In any manner an as w become subject to the Warlaus Compereedan
Laws of Califamia.Dae
Applicant
NOTICE TO APPLICANT:If,arm,making this Ceni0ci a of Eacmptian,you should
become subject w the Workers Compensation Provision of de labor Code,you must
.JZ fothwtth comply with such provision m this Permit shall be damcd revoked.
ZO CONSTRUCTION LENDING AGENCY
[-� Ibureby.M.lits,Nem is a construction lending agency fm the Performance of
ef, use work for which this permit is Issued(Sec 3017,Civ.C.)
WQ Lender's Name
CL,
.`7. Z lender's Addres,
(„)Q I certify than I have nod thisapplication
and
and duan that the aka I"relatlw u
C)r+ building 1 agree w comply with all city and coumy ordinances and sank bas r upon t e
Q building construction,and hereby euthod purposes.xnWiaes of Nis city to enter upon the
W ahovo-mdntion re to ny,for inspection Proposes
4 (We)acme to an,Indemnify and hap harmless drt City of Cupdnino agarol
y in
nconlequencmenueseal and ex pens ea which may any w'aY.cera galmtWO Clly
U inc.nneganec of the{Holing of this Penott.
^' APPLICANT UNDERSTANDS AND WILL PLY WITH ALL NON-POINT sue by: Date
Sall REGU ONTI" O ` u
a C e-roo s
Signature of ApplicanUConuactor I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle huatdou material
as de0ned by the Contends.Municipal Code.Chapter 9.12,and the Health and Safety
ad.,So line 25532(11)? �, All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant sea equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haaardnas air contaminants as dcMcd by the Bay Area Air Quality Management all new materials for inspection.
District?
f]Yn Nu
Ihave mad the hasardnusmaurials re qui esu under Chapter A95 of the Glifor.
n' Health&SaktyCodc.SbN.n 25705.35577 255Je.lundcuunitheifdebuil ng ;7— 7'
not cunt ly baa ytEnent Nat i,ts my portability in redly the scup o the
a hie m st met 'esu of,Ceninam "� j t e Of Applicant Dale
t O
Owner nr.nm rivaa actin Daan 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
�UPERTINO
Building De artment
JOB i DDDRESS: ✓ ( � PERMIT#o q 0
OWNER'S N PHONE # 8 Lo L-G5
GENERAL CONTRACTO • G # L'Con SQ0
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
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile i
Owner/Contractor bignatureDfate
CITY OF CUPERCTINO �4 o
CUPEi�TINO PERMIT APPLICATION FORM Lt
APN #5l / ,Z � o J Date I O
Building Address: GLGQ
O I
O bN n I Phl�oone#:
Co r ctor: e l\ /v hone:l O� �y� i _9 S icens-7
Cont t: Php�e: D Cuperti o Business License #:
�tc���2�-- "l.p g' g Ce ( �amu. �
Building Permit Info:
Bldg (E]� Elect ❑ Plumb ❑ Mecham--
Job Description:
ResidentiCommercial ❑
For Residential Installations:
Attic ❑ 1 s` floor ❑ 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 Planning Approval Required ❑
Cost of Pr ect: D��e of Constructio Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbina Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Licen BUILDING