05090172I
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CITY OF CUPERTINOx'a.,'%+"'F^'•`'"
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�CONTRACTC4R�IN'FORMATION
BUILDING DIVISION PERIVIIT
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BUILDINGADDRESS:
SUPREME AIR SYSTEMS
PERMIT NO.05090172
1 24
OWNER'S NAME:
PERMIT ISSUE DATE
RAMI RUBIN
80 GILMAN AVE
09/26/2005
ONE:
SANITARY NO. CONTROL NO.
(408)376-0406
ARCHDECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that I am Iiceacd under provisions of Chapter 9 (commencing
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with Sudo. 7") of Division 3 of the Bux. aid Refeeduoa Code, and my license is
in"' forte and e L j —7
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ADD A/ C`�Il
License Clear ' Z lac. A r
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Dam Conlrxur .� �
ARCHITECT'S DECLARATION
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I understand my plana shall be used u public records
OCT 1r' 2005
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby ,(Sect that I LIee.Y Law for the
exempt from mC essions,
Co o
following won. (Sadat T(D IA, Business and Code: My sly or county
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( t
vex. deiom
which require a permit alma imprtve, m signed
comuires
, ,], 21_ .Q
dcL
re h permit t e a statement
prior m its lensed p also require de applicator ot fu Inch permit w 61eo,lyres Cerement
thaheeNicenwit pumtmUothe prevision of the Conmcrosand
Sq. Ft. Floor Area
AL--+'=ValuAtilinU
Prwlaw(Chaper9
exewith 7ODM of Code)of
7 dfthe Bed
andtheDasisfon
'hat he hcmfm exemption.An vi
the M1e V exempt dertMm and the buts for then steges eumpdon. Any violation of
-5 AP14 WdifillidY U U
Occupancy Type
Section 7031.5 by any applicator for a permiuubjuu the applicant o a civil penalty of
not mom than Rve hundred dollen ($5003
❑ I,uownu a(Iha property.amy employcea with wgesaa dev vele compenudon,
Required Inspections
wllldo the wmk..nd theuucum I. rwtiutumed or offered fertile, (Sec. 7044, Business
and Profeasiu . Carts: The Caneor's License Law doer not apply to an owner of
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property who buildsorimptom thermn, andwho doeaanchwmkhi.lulf or Woueh his
own employee, provided dust such improvements are not incensed oarremd ferrule. IL
however. the building or improvement is veld within one year of completion, de owner.
builder will have the burden or proving that he did ret build or improve for purpose of
sale.).
❑ 1. a owner of de property, am exclusively contracting with licensed contractor, w
construct the project (Sec. 7044, Beim a and Promaloa Code:) The Contractor's LI-
ccom law does not apply w an owner of properly who builds or improves demon, and,
who contracts for Inch prejecu with a connncwNs) licensed pursuant to the Contrmor's
License Law.
❑ I am exempt under Sm , B k P C for this mean
Owner m
Da
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following condensation:
I haw and will maintain a CertiRnte of Consent w ulf-insum for Worker's Compen-
utfee. u provided for by Section 3700 of the labor Code. for t e performtoce of de
work: for which this Permit is belled.
O 1 have and will maintain Workees Compensation Inarranm, u required by Section
37gl of then tabu Code. for the performance of the work for which this permit is issued.
My W.r is Compensation leuv n�n, carrier �anSp� Polity mrsonc re:
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CCgk rutG9odcy No.2p-3 n__
CER71FICAT E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section uad not W campleted lithe permit 4 f.romhunsreddollua(5100)
or leu.)
I certify that in the performance of de work for which Nis Permit is issued, I Nall nm
employ any person in any mannerm a m becomewbjecl to the Workars' Compensation
Laws of Ca if nnia, Dam
-
Applicant
NOTICE TO APPLICANT: If, after making this Corit cam of Exemption. you should
become ,ubjm w the Worker's Compensation previsions of de Laden Code, you mum
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forthwith comply with inch "Actions or this permit (hall he domed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby a(Trmn that them is a emuuuctinn lending agency fume puformaruc of
de work for which this permit Is issued (Sec. 3097. Civ. C.)
'
Lender's Name
Lander'. Address
I certify that I have read this application and sum Ne the above Information 1.
correct. 1 agree to comply with all city and county ordinances and sere laws reining 10
Wilding convection, and hereby authodu representatives of this city to enter upon de
above-mentium l properly for Inspection pugMYL
(We) agme to ave, Indemnify and keep harmless the City or Cupcnim agaiat
Ilabilhinjodgmenu musedexpcims which maylnanywayamue.gnut old CllY
In consequence car granringer peMIL
APPLICANT U RSTAND ND WIL OMPLY ALL NON -POINT
Issued by: Date
SOURCE REG A ONE.
Re -roofs
Type of Roof
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Slgnalurtof Applic ConRDO Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the ePplieam or future to occupant Ms or handle arduus material
u dcOncd by the Cupertino Municipal Code. Chapter 9.13. and de Healon and Safely
mm.Secu.nu53x.)±
All roofs shall be inspected
to any roofing material being installed.pyea
M44,
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
It haxardous air contaminants a dunned by the Bay Area Air Quality Management
all new materials for inspection.
stricO
El Yes FNo
I haw read the huardm, materiels requirements under Chapter 6.95 of the Califor-
niaHulthB afety Case,Sardau23505.75577 and 7553/.l undnmarld thuif the building
sou role nllY how, mn4 duslhts yma thililYmn.dfY de axupantnf the
require ts hichmu mepri., u isc.NRnteofoccupamy
Signature of Applicant Date
ZG K
All roof coverings to be Class "B" or better
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cru oda cot Dam
fi
OCl OF
UPEkTINO
i
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
2L40 Pr
PERMIT #
b 5vq��7Z
OWNER'S NAME:
SUBCONTRACTOR
PHONE # a
GENERAL CONTRACTOR: l
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
�-7,� -0 S -
Date
RI
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
V
Heating/Ac—
eating LInsulation
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�-7,� -0 S -
Date
11
•
a CITY OF CUPERTINO
FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # .S Z ! ` Z
Date:
Building Address:
OD -yo Qhgr Lc
BREMFURN
Owner's Name:
C�.�b`�
Phone #:
ka'13 9
mt n
A/C Unit > 10,000 cfm
Contractor:
S rem�
License #:
7-7 Yo 6(o
A/C Units <= 10, 000 cfm
MECHANICAL
Contact:1— r
r 1G. txt
Cupertino Business License #:
Building Permit Info:
BSEISMICRE
Bldg ❑ Elect Plumb E�-
Mech
Job Description:
Elec Permit Issuance
Residential [P Commercial ❑
MPERMITFEE
For Residential Installations:
MECHANICAL
Attic ❑ 1" floor ❑ 2"d floor ❑
Plumbing Permit Issue
Adhere to min set back re uiremento
BPERMFEE
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) ❑
Plan Check Fee
Structural Calculations required for new installation ❑
BUSLIC
New installation Planning Approval Required
BUILDING
Cost of Project: Type of Construction:
Occupancy group:
tan o -
Strapped El On Platform Bonded LJ
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
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