05020027C
'
CTTY OF CUPERTINO
BUILDING DIVISION PERMIT
CON�2AURTNIkU.tMA'Y'Yp1V;
BUILDING ADDRESS:
A PERFECT CLIMATE
PERMIT ND05020027
OWNER'S NAME:
PERMIT ISSUE DATE
DONNA
ONE:
SANITARY NO. CONTROL NO.
408 861-9545
ARCH=1ENGINEER:
BUILDING PERMIT INFO
BLDG
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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I bunchy affirm that 1 Am Iicenecd under provisions of Chapter 9 (commencing
ML Section 7000) Of Division 3 of the Businum and Profeedou Code. and my license b
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inful oZa"deOe0.�/�/,''�'aa��vv ��e�
REPLACE FURNACE & ADD A/C
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-
Date
Dau COnuamor
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ARC S DECLA ATI
all be
1 uMcnund my Plana elull be used u puNu records
b)
u
Licensed Pmfeuieiul
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3
DECLARATION
Oat
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1 busehy that I em. from the Cuntrns
I am exempt treat taw for tbu
My
O
. (Sect Burin Cade: My city or county
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following maven. (Sadao RD1.5, Basimai and Re,
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g�
dam l
which requires • e,almre emunhe Blue h,Pmve, demo)W, carea sig any sanscorm
primwiu iumncpumam in the theeappliotef forme suchpeme'. .cal&ncdauumem
is of dirt ComruwfWceroelaw (Charm,Code)
119000
Sq. Ft. Floor Area Valuation
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pursumt7")
(come
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Disiau
mein with of
Budwamtlon. vi Co dc) of
Axe ndth
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tham he ptterefore basisonlaftbu
that he u exempt therefrom roti the bub for the alleged exemption. Any vloladm of
Ay
10 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man five hundred dollar+ ($5001
❑ L As owner of the property, or my employe with wage As thei�g�g�le comp session,
will do the work, and the smrcwrc bnotintended oroffered fair au(Sec:UBotinae
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and Profetiou Code: The Comacur's License Law deo rot Apply w m'awodr of
Re aired Ins Actions
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property who bulldsor improvvthereon, and whodoeamch work himutfhrthroug5 bier
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Ownemployes, pmvided that such lmpmvemenu ae not intended ocaRered retail& if,i
Whoever, the building or lmpmvemmt is mid within one year ofcompledon; the home.
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Wilder will haw the burden of proving Nat he did not Wild or Improve for purport of
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caul,
I T 4v �
I
n owner Of the to
❑ property. am exclusively cmmcang with Ilanaed sun sun w
construct the 70W. Business Professions Code:) The Cmtracwri Li3-
L7
project (Sec. and
ceue law dma not Apply in an owner of property who bulkat or Winuma demon, me
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who contracts for such prokcu with a eonuactm(s) licensed format in the Contrmtah
License Law.
❑ 1 am exempt under Sec. . B h P C for this mason
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Owne Data
WORKER'SCOMPENSATIONDECLARATION
I hemby amnn under penalty of perjury aro of the fallowing t aimatione:
1 have end will maintain n a CaNEcate of Cement w ulRluure for WorteYa C.P.A.
anion• u provided for by Section 3700 of thc tabs Code. for the performance or the
work far which this permit It WOOL
ve and will maintain Worker's Compensation Insurance. u required by Section
of the labor Code• for be performance of the work for which this permit is issued.
My Worke sup mado�lnw ae camier and Policy number arc:
Carries: ( Policy No.:
C•RTIFICATEOFPX Pf10NFROMWO KERS
COMPENS ON INSURANCE
(Ibis union mad not becomplowl tithe permit lsfaom hundred da0.n (SIM)
or leu )
1 unify that in the pcopmeuuo of the work for which this permit is Issued. l shell net
employ any person in my mmarm As an bccomesubject w the Workeri Compenssdm
Lew. of Callmoula. Dau
Applicant
NOTICETD APPLICANT: If. after making this CcniOeme of Exemption, you should
become subject te the Wonke s Compensation provisions of the labra Coca. you man
0forthwithfowith
comply with such pbu mvisihns or this permit mail dimmed mwked.
CONSTRUCTION LENDING AGENCY
'
Iburebyaffirm that thcrt Is a construction modingageney for tha Performance of
the work for which this permit b issued (Sec. 3(197. Civ. C.)
it
2
Lender's Name
Lender's MOmss
Q
I certify that I have read this application and sum that de above information is
I ogee m comply with all roti county ordinance and eau lows elating e
Ucorrect.
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builungemuried o0.and heeby authodmmpreunutivea of this in enter upon the
alb
W
ehovo mendonc0 property rowdmpection putporeA
&L
pl
(s,j g ma m mw• indent y and tap hamdw dw y c ri eupenst s against
I. .ch nand ex which may In my wry memo against said City
1
consegencea the ting of reit.
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F7i
APPLICANT
APPLICANT U D STANDS A WILL COMPLY WITH ALL NON -POINT
U A
Issued by: Date
SOIJRC-E'REC A DNS.
Re -roofs
a
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Si&narurc of ApplicmUCOntrutor Dau
HAZARDOUS MATERIALS D CLOSURE
Type of Roof
Will the applicant or future building occupant ore or handle huardous material
u deEned by he Cupertino Mir ici I Code. Chapter 9.13, and the Halth and Safety
ode. Section 25532(a)7
[3y.No
All roofs shall be inspected prior to any roofing material being installed.
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 lo"amus air cantmqtu deBd by the Bay Arta Air Quality Management
rd u a
'mitt]
all new materials for inspection.
\w
❑ Y's
Ihavemad the mrd/—(nautiebmqu menmunder Chap ,11,95ofdu Cdi(or.
Hcalthasafayc
ria and 25505.2553 25531. ImdemaM dmuue helium&
dxamtcmenny he .0 ant. in., it b my alley m Wofydeaft
coperna
mgairemenu which at Aid,W met me .CeNfuate ofnpuey.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner e..their=d agent Data
CITY OF
,UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT �.�; 62-0027
OWNER'S NAME: Q_5
PHONE # �i08 e25
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor
07 0,3, O's
Date
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
Til
Owner/ Contractor
07 0,3, O's
Date
UPEIZTINO
CITY OF CUPERTINO
FURNACE/AC U S `' Z ° ' ?,7
%
PERMIT APPLICATION FORM /
APN #
�3/ -3
Date:
c;2-3.0
Building Address:
BREMFURN
I0�..3D
MECHANICAL
Owner's Name:
Phone #:
MECHANICAL
a55
Cont r Phone:
License #:
�- 1MB / - q545i3
Rec tl, Switch & Outlets
Contact: AC� Phone:
Cupertino Business License #:
Seismic Fee Res
BUILDING
Building Permit Info:
Seismic Commercial
Bldg ❑ Elect Plumb ❑
Mech
Job Description:
ELECTRICAL
�
� G
Residential ommercial ❑
PPERMITFEE
For Residential Installations:
PLUMBING
Attic ❑ 1" floor A 2"d floor ❑
Bldg Permit Fees
dhere to min set back re uirement❑or
BPLANCHK
Commercial Installations:
BUILDING
eplacement same weight E]-. Additional weight (structural calcs) Eltructural
Business License
Calculations required for new installation ❑
lN
ew installation Plannin A roval Re uired El
ost of Project: Type of Construction: -
Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
A
Fre Dngcrintinn
Fee Group
BENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER'
A/C Unit > 40,000 cfm
MECHANICAL
BREMA-MiAN
A/C Units<= 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
_ BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILIDNG
EPERMTTFEE
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
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