03090160CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRAC"TORINP'ORMATION
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BDILDINCADDRFss:
A PERFECT CLIMATE
PERMIT No. 03090160
OWNER'S NAME:
10570 S DEANZA BLVD
FEW" ISSUE DATE ,
HE
(408) 861-9545
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSEDCONTRACTORSaOR'SDECLARATION
Job Description
I hereby the,1 am limed under of Chapter 9 (commencing
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Preoss
with Section ]dAffecDivision 5ofthe Busine and Professions Code. and mylicense u
)of and
in full force and effect.
License alma Lk.g
REPLACE FURNACE
Doc Contractor
O
ARCHITECTS DECLARATION
1 understand my plans CHI Mused mpublic ATION
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Licensed Profcesinnal
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from ,he Contractors License Law for ,he
following mason. (Section ]11]1.5, Business and Pmfevioru Code: Any city or county
which requires a permit to ennxrw:t, alar, Improve, demnikh, n, repair any atruc,um
d:111 Q
prior to its issuance, also requires the applicant for such parmiLto file a signed ttalemem
that he is licensed pursuant o the provisions of the Contractor; License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section ]BBB) of Division B nf,he Business and Professions Cafe) or
'Air2inslq
that he is exempt therefrom and the breis for the alleged exemption. Any violation of
nn
APN Number
Occupancy Type
section ]051.5 by any applicant for a permit ubjects the applicant o a civil penalty of
not mom than five hundred dollars (M).
❑ 1, As owner of the pmpeny, army employees with wags As their sole compenaatlon,
301 - ROUGH rfufrgT� r�T
iCHANICAL
will dote work, and the swcure is not intended or .freed Tonal.(Sec.]044, Business
and Professions Code: The Contractors License ans Law dnot apply to an owner of
WiYAY 3fF�LCIIODS'
property who builds of improver thereon, and who does such wort himselforthrough his
303 - ROUGH M
own employees, provided that such improvements arc not intended or offered for sale. If,
304 — ROUGH ELECTRICAL
however, the building or improvement is seld within one year of completion, the overt.
builder will have the burden of proving that he did not build or improve for purpose of
505 - FINAL ELECTRICAL
sale.).
507 - FINAL PLUMBING
1, as owner of the propeny, em exclusively contracting with licensed convectors to
construct the pmject (Sec. 7044, Business and Pmwsiom Cade:) The Contractors U.
508 — FINAL MECHANICAL
ecnx Law doss nu, apply m an owner of propeny who builds or improves themon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
I am rept/under Sec. , B & P for the reason
net �<^...... L CxCx� = r-T'4� _ Dak �- O
WORKERS COMPENSATION RATIO
1 hereby affirm under penalty of perjury one of ,he following declarations:
1 have and will maintain a Cenificam of Cons alto self insum fur Workers Compcm
auto, as provided for by Section 57W of the Labor Code, for die p Marro mea of the
work for which Nis permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, m required by Section
37W of the Labor ewe, (or chic performance of the work fns which this petmir is issued.
My Worker's Cnmpemaibm Imumnm entice end Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EK EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomple,ed KIM permit is for ooc hundred dollso (SI W)
,it Icor.)
I ceni fy that in the performance of the work for which this permit is lamed. I shall not
employ any PC.. In say an., al a5 in CCamr 3object IO the Wmkc,s Gompenxll..
'
Laws of California. Dar
Applicant
NOTICE TO APPLICANT. IL after making this Ccnitee of Exemption, you should
become subject to the Workers Compensation previsions of the labor Code, you mus,
forthwith Comply with such provisions or ,his Permit&hall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemby affirm two urate is a construction lending agency for the perfurmmme of
Ne work far which this permit is issued (Sec. 3091, Civ. C.)
Under's Name
Lender's Address
1 ccnify Nat I have read shit application and tum the, Ne above information is
correct. 1 agree ,o comply with all city and county eminences and state laws totaling to
building contraction, and hereby authorise representatives of Nis city to enter upon the
shove-mode aped property far inspection purposes.
(Wo) agree to save, indemnify and keep hamless the City of Cupertino against
liabilities, judgments, costs and expenses which MAY in any way ascetic against mid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH L NON-POINT
Issued by: Dat
REGULATIONS.
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G1_ °
Re-roofs
Type of Roof
ofApplicanVConomorarcHAZARDOUS MATERIA DISCLOSURE
ill the applicant ser future building m am store or handle havemuus maedal
rC.dcrincd by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safetyion
25572(a)?`/All
®Noto
roofs shall be inspected prior to any roofing material being installed.
Yes
a roof is installed without first obtaining an inspection, I agree to remove
ter apprmm�,ar mare banding ceotpam tx equlpmenl or device, wm<bIf
rdous air contaminants as deftncd by the Bay Arca Air Quality Management
all new materials for inspection.
❑Yes Nu
I hew mad the bvrdaus materials occome enu under haper6.95oI the Caliar.
aia Health&Sare ty Cade. See a ons 25505.25533 and2555a.1u mond dust, WiiJing
Joel not Currently have • enam Na i, it my ruponsiM1ility to ufy de cupant of the
requi enswnkn must le melpdortoinuaacofaCcnific ori
Signature of Applicant Date
1
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All roof coverings to be Class "B" or better
owner
or atthorized ascot D ,e
•
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,
QTY OF
CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
APN #
Energy
Building Address:
BREMFURN
10 ( a 11.7FrL. A -v F�
MECHANICAL
Owner's Name:pp
Vt�L r'i,`%'I G
Phon/e #:
.c-
ontractor: Phone: !_ �5
/
License #: 7,73/,5-8
g< -T CLIk Tz
MECHANICAL
Contact: Phone:.
i
Cupertino Business }��use #:
�7 '
Building Permit Info:
BSEISMICRE
/
BUILDING
—
BldgElElect IAV Pjumb ❑
Mech Cid'
Job Description:
MPERMITFEE
ResidentialCommercial ❑
MECHANICAL
For Rgidential Inllati ns:
u & ❑
Plumbing Permit Issue
151 floor 2"" floor
Attic
BPERMFEE
Adhere to min set back requirement ❑
BUILDING
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Plan Check Fee
Structural Calculations required for new installation ❑
BUSLIC
New installation Planning Approval uired
BUILDING
Cost of Pro' y, of Constructio
Occupancy gro p:�
Strapped On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Re lacem nt
Qty. if
A,. l; A<I-)*
FPA Tr)
Fee, Deccrintinn
Fee Group
BENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAH AN
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
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