05120015 CITY OF CUPERTINO
BUILDING DIVISION PERMITC,ONTRACTOR*I�N ,ORMATIO.N
BUILDING ADDRESS: A PERFECT CLIMATE PERMITNO.05120015
1575 POPPWy
OWNER'S NAME: PERMIT ISSUE DATE
Ajk KRISTIN RALSTON 10570 S DEANZA RI=
NE:
SANITARY CONTROL NO.
19 (408) . 861-9545
ARCHITECfyENGINEER: BUILDING PERMIT INTO
'BLDG ELECT PLUMB MECH
0 r
30p LICENSED CONRACIOWS DECLARATION Job Description
lZ C 1 Washy&M m Nat 1 am limaxd under provisimu of chapter 9(mmmcasin{ !/v
no with Secdon 7")of Division 3 of Ne Storm,and professions Code,an my lice�is V
<N inflif naad4IT REPLACE FURNACE & ADD A/C
s— Lbenx CT Lk.p
e=o Dam Gomramr ✓ry'I y�f
As about use Ds bit ATION
f�� 1 undcntanJ my plans slWl ha used v public rmorrk
e Liucnxd Pmfcssianai
5 Oa, I am apt fro DECLARATION
I hctoby sirs Nat I am rumps from the Cantnctah IJccns Law for Ne /Cpp�y!pJl v
a o fallowing oven.(Section 70313es
.Busins and Proreaiuns Code:My city or county
3 29 which notion.a pcmit to construct,alar,improve,dcatolim,or mpair my suuetum '8 7 Z S
prior to its issuance.Ms.r .I.tMapplicantforsuch permit to file asignrd statomcm
eke NuheislicensedpmsumtmNcprovisionsofNeCompactor'sLuxeLaw(Chap=9 Sq.F[. Floor Area �dlua l
u (commencing with Section 7000)of Division 3 of NC Business and Professions CaJe)or
r3
that he u exempt thmefrom and the burs for the alleged eaempdon Any violation of
Section 70315 by any,applicant for a permit subjccta dm applicant to a civil pmuhy of r U U Occupancy Type
not more Nm five hundrod dollar($50)).
1,v owner of the prvpeny,m my mploym with mget u doh mk camp melon,
will da the work.and t:rhe tont a us's Li ed or Law
do fwrak(Sm.70/4,Busk•
and properly
who nes Cade:The CammcmrY Livwho law dais rut appy m rn awns is .Required IDSpeetlons
proputy who buildnorimpmvet Hereon,andwha dmsamW wank himselfor through his '
awnmplayec,pint or MarsmWi t.I,of witti.eat ims f orwocrsrs for owns.
W ii&r Ne building or Imgaveromtg old within old Weld of improve for the owncm
builder will have the burden of proving Nal he aitl not Mild or improve far purpose of
sale.).
1,as owner of tha proporty,am exclusively contracting with Bmmed convectors to
construct the minor(Sec.7044,Business and Rafessov Cade:)The Conmcmr's Li.
cense Law docs not appy to an owner of property'who builds or impmm Meson.and.
who mno m fm such Miem with a eonuacwr(s)li¢nxd ptmuant b tha ConvutaYs
License Law.
❑Immumptundm5ec ,B&PCfordusmwn
Ownu Dam
WORKERS COMPENSATION DECLARATION
1 Woolly affum under perwty of pmpuy ons of tha following decimations,
I is,a and will maintain.CeniBeam of C..a,to self-insure for WarkchCompcn-
sadon,as provided for by Sccuon 3700 of the Labor Code,Its than perfams.of the
wart for which this pi,is iswN.
❑1 have and will maintain W slacra Compchaw..Insurance,as squired by Sc onion
]700 of Ne labs Cade.Im ds perfomanm of cite vert fw which this permit u'....^ '
My Workee mp/pe+n��sadon Insurance carrier and Policy n mbar o:
C.
of lSH all,No.: AQ
CER IFICATE OF EXEMPRON FROM WO (ERS'
COMPENSATION INSURANCE
(Thuxcdrn aced wtl c completed if Ne Nook k for one hundreddatlars($100)
or
I csmfy Out In the perfarmmec of rho work for which this permit is w�ttl,�I owl not
cmplolemypc nmmymms+cr suuloix runcsubje.tuothe Ww 'Compensation
laws of Caiifa�Dao:
Applicam E.k n
NOTICE TO A�.CANT:If.a rbc making this Cenificam of Exemption,you should
become maim W the Worker's compcvadon provisions of Na Labor Cons.you most
.,,z forthwith comply with such provisions or this Mmit shall In dcemed mated.
Z O` CONSTRUCTION LENDING AGENCY
�-+ I hmaby afEm thaz Neo is a commctum boding agency far the perform.of
C4 thr wish for which this pemit in Wood(Sec.3097,Cin C.)
A Lenscra Nma
= z Lendser Addoss
U Q 1 certify that 1 have read this application and sato that the above information Is
I7. F Comm I agroe to Comply with all City and county amBnsum and sato]am totaling to
O V huildin{con firm.and hereby authodm topmxntauvet of this city to wrmrupon Nr
Ct7 above-mentioned pmperty for inspection purposes
6. (Wc)ag.to save,indemnify and keep b rmlm tha City of Cupertino against
T/1 liabilities,iudgmem d.cosy aha expenses which may in my my amus against said Cry
t)Z in consequence of the{ranting of this pemir.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signazurc of AppliaDOU Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Nr applicant or( ono building arupanLst9.1 or handle huemlaamams
ri
as dcBrud by tine Cupeno(Mono
Code.CWaptor 9.17,and do HcoN and SaRty
mlc.smtim zss3zfa)rti? All roofs shall be inspected nor to an roofing material beim
❑res pNd— P P � Y g g installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will Nc applicant or forum building occupant use cyuipment car dcvim which pe g
emit harardnv air comamiwra v mcd by the Bay Asa Air Quality Mm.gement all new materials for inspection.
D sat m?
❑Yet No
1 have road the IuvNtuamau rials mquiremena unJcrChaprer 6.95 of Ne Califor.
nia Health&Sandy Coda.Senom2M5.25.533and27534.lundc and Nazifthc Wilding _
dam rml cumnlly hato.tonanc Nal it u my roaponsibilirY m notary dto mupmt car Nc
tognirorwma which mea be mel prior to iawmca of a CwBcam of Occupancy, Signature of Applicant Date
own,or autho and aCm Dam All roof coverings to be Class"B"or better
Community Development
e 10300 Torre Avenue
Cupertino CA 95014
s Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S N -PHONE # d — s7
GENERAL CONTRACTOR: AX #
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
Owner/Contractor Signature Date
CITYOFCUPERTINO
� TYOF hUROACE (Adl.'
2
CUPEkTINO PERMIT APPLICATION FORM V
APN # � z Date: Z S�
Building Address-
Owner's
dress:Owner's Name: Phone #:
,YDS ' v-\ f'-,' /50 37
Contractor: L License #:
Contact: —R Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect f� Plumb ❑ Mech M/
Job Description: /4cp A4
C-
Residential l Commercial ❑
For Resilyatial Installations:
Attic a I" floor ❑ 2"d floor❑
Adhere to min set back requirement 1tr
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Projec p7�s� Type of Construction: Occupancy group:
O O d
Strapped ❑ On Platform ®— Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
tl 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 Licen BUILDING