05060041 CITY OF CUPERTINO +
BUILDING DIVISION PERMIT CONTRr1CTOR�INF,URMAT,ION
BUILDING ADDRESS: AIR QUALITY HEATING & AIRC @aMtT"D.05060041
OWNER'S NAME: P®MIT ISSUE DATE
NE: SANITARY No. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BO 0 PLUMB 0
o a LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division S of Ne Business and Professions Code.and my license is
ED
z�— In eareClull aand erceet �% REPLACE A/C � �,u p
z Z Lkenm Class Ls.g - t, t
Data CamraECL
,e
ARCHITECTS TS DECLARATION
y� 1 urmdcrsand my plana Mall be used as public rocnrds �oo�
3 G Licemed Professional
a'y OWNER-BUILDER DECLARATION
0 y I hereby a(Bnn that I t. aempt Rum the Communes o e:My c Ism for the ^ I� p ly ��.�+� rk\(� /�
D O fallowing hereby
(Sadao t I am.Busimfi and Profession Coma Cade:My city w county lu}l 'I I`I JJJ\Jl lj\i t\(`�^l
$ which equims•permit m consuun,atter,improve.demrJUh:m repair any muctue
f S^ prior km its issuance.also requires the applicant for such permitm file aligned statement ., ----- -
that helsliansedpurmanttothe provisionoftheConlractur'slJanrefiw(Chapa9 Sq.Ft.Floor Area Valuation
S (commencing with Salion70Do)of Division 3 of the Busuessand Professions Cock)or
33 that he 0 exempt therefrom and the buLL for the alleged exemption.My violadan of
Section 7031.5 by any applicant for•permit subjects the applicant to a civil penalty of 3 WIl18'lUMW O 0 Occupancy Type.
set mom dun five handed dollars(S500).
❑I,ssownaof Nepmpeny,wmyemploymwithwaguutmirmleeompeneadon,
will do the work,and the structure Is not Intended or offered for sale(Sec.7044.Business; Required Inspections
and Pretensions Cade:The ConhmmYs Liaisen Law doact apply m ns an owner of q p
property who bulldsnrimprowa thereon,and who does such work himself or through his
own emplay.,provided that such Improvements rte oat Inmoded a offered far anis.If.
however,the building or improvement is mid within ort year of completion.the owner-
Wilder will have the both.of proving that he did rot baud or Improve for purpose of
sok.).
❑I,as owner of the property,am exclusively contracting with licensed comma n;to
construct the project(See.7044,Business and Profasions Cade)The Onnaacmri Li.
cense Law dao not apply to an owner of property.wha builds or improves thereon.and
who contacts for such projem with a eonwemr(0 liamed pursuant in the commute,
Lkenm Law.
[:]I am exempt under Ser. .B h P C for this mann
Owner Date
WORKER'S COMPENSATION DECLARATION
I thereby affirm under penalty of perjury as of the following declination:
I haw and will msinuin a Cemfiamof Conant to self-inma to WokeenComport.
731M
ion,as provided fo by Secuan 3700 of the Labor Code.for the performame of de
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the Lebo Code,for the performance of the wok for which this permit is Wood.
y WarkeM1 Cnm�pe�nati/an Imurarme nrrier and Policy number am: o/rrier: 5 /411 (G ✓ aliry No.: b ,
CERTIFlCA OF PITON FROMW RK S'
COMPENSATION INSURANCE
(Thts section need nutbe completed lithe permit Isfnranc hundred dollar($101)
or less)
I certify that In me performance of the work for which this permit is issued.I shall not
employ any person In any reamer an as in become subject in the Workers'Compeasstian
Laws of California Dam
Applicant
NOTICE TO APPLICANT:If.Ater making this Certificate of Exemption,you should
become Subject to the workees Compensation provisions of me Ixbnr Code,YOU must
0 Q forthwith comply with such provisions or this permit shall x darned revoked. ..
Z'4 CONSTRUCTION LENDING AGENCY
(-mom Ihercby.M.out mere is•conmuninn kndingagency for tie perfomana of
04 7 the work for which this permit is,tssad(Ser.3097.Civ.C.)
0.i Q Ltndcls Name
z finder's Address
V Q I readily oras I have mad this application and sue mat the aWw information is
U. eorect 1 agree to comply with sit city and county cNtoaam and sae laws eclating in
0 SV' building construction.and hereby mtharie representatives ofmis city to color urym the
show-men0oaed property for inspection purpmes.
LF^i gy (We)agree in ave,indemnify and kap harmless the City of Cupertino Mins
r+rA liabilities.judgments,casts and expenses which may in my way acne against said City
D 7 In consequence of the grating of ibis permit.
m1— APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date GT-6-,('
SOURC^ EO LAT30 a
6 Re-roofs
SignspreofAppueanVCormaxor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fume building occupant roe or handle intimation,material
as dcMed by the Cupertino Municipal Cade.Clap cr 9.17.and the Health and Safety
.dc.S❑Yeruan All roofs shall be inspected prior to any roofing material being installed.
Witl thppicman 1;�.or future building oaupam um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
is b4za dnus air contaminants as defined by tbe Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea
I have reW me haraNwa maeiaH requirements under Chapter 6.95 of the Califor.
nia Health k SaelyCode,Sections;7550.25533 and 25534.1 undermand the irdm building
dao not currently haw a Immmt s it u m no
my responsibility tify the occupant of the
equtmenenUs hkh ust be met ser m amanceofs Certificate of occupancy. Signature of Applicant Date
Owner or shadzc amens Date
All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aaOF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMTr#
/17,2 r %yt ve- rtiaS-o 6 80
OWNER'S NAME: o PHONE#("Y,, Jr)
GENERAL CONTRACTOR. AiQ L6v FAX#
OVA/ ry
I am not using any subcontractors: //
tgnature Date
Please check applicable subcontractors and complete the following information
60 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
CITY OF CUPERTINO /
FURNACE/AC
2CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: Phone#:
o a V.2 - o�
Contractor: License#:
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect f�- Plumb a Mech FKr
Job Description: /
Residential J;� Commercial ❑
For Residential Installations:
Attic ❑ 1" floor R 2"d floor❑
Adhere to min setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
C st of Project: Type of Construction: Occupancy group:
d u �
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfin MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
/ EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
/ PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING