04030150 CITYOFCUPERTINOn'9 ` � ' ' ' "'"' � ^'� "'`BUILDING DIVISION PERMIT v?CONTRA.CTOR++INFORMATIONu
BUILDINGADDRESS: A PERFECT CLIMATE PSRMITNO'04030150
OW NER'S NAME: PERMIT ISSUE DATE
VICTOR '11
ONE: SANITARY NO. CONTROL NO.
4
ARCHITECDENOINSER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�o� LICENSED CONTRACTOR'S DECLARATION
1 hereby afflrm that 1 sm lured under provisions of Chamer 9(commencing lob Description
withS=ti.n7").f Divinon50f Ne Busirws ftfcs ons Code.udmylkenmts
mouse Cam eRecL FURNACE REPLACEMENT
LV License Clus Conti
t Dam Contractor
,e ARCHITECT'S DECLARATION
y 1 undersand my plans shall be used as public rccnNa
76
G
Licensed Professional
OWNEen esemDER DECLARATION
I I hereby.(Em that 11.ursine from cite CmlcomCo License law for the
O O following moon(Saito Some t.aper, and Professions Cale:Any city ar rounry
$� which rtqussu•peril m ums th t alar,improve,demolish Permit t o repair any un murn
tt
pith m its issuance,pursuant elsu require Ire applicant tforhe Contractors
ola permit mice s sign.(Current
tz?Fp< that(com iscingwi dsasreofDiaionso3thftB..i w .LdPmf Le.(Chapter c)or Sq. Ft. Floor Area Valuation
3$ (cerrorandng w t thcur xem and)me(mason r nf,M alleged
exempt on.AnynnsCnde)or
lk 3
that he"I.Carpe therefrom and Ne buil for Ire We{ed uempJan.Any violation of
Session 7001.5 by my applicant for a perm mbjecu the applicant to.Civil penally of 3 ABN ISOih&r 0 0 Occupancy Type
nm mart Nan Eve hundred dollars(SSW).
❑I,aamwoerof Nepmpenyormyempl"mwlNwguutheirmlewm me m,
will do she work,and the nmmum is nolinunded oroRered forsam(See.7044,Bunions Required Inspections
and Prosstions Code:The Com utas Lixuee Law does not apply m e an owner of q P
property who bulldsorimmons thereon,and who dosuuchwork Mmself orNrough his
own employees,provided that such improvememe tee not intended ooRered ferrule.If.
however,the building or improvement I.mid within one year of ccmplesion.the owncr-
Wllder will ban the burden of proving that he did not IW Id or improve for purpose of
ilk.).
❑1,as ownsr of she property,am exclusively contracting with licensed conausors he
construct the project Sec.]BM,Business and Professions Crain)The Contractor!U.
cense law does not apply he an owner of property who Wilds or improve thereon,and
who concocts for such projects with a eonumber(s)lirzved pursuant mthe ConlractoM1 R-
I
Lkenm Ww. tI am e.emptt Ott Sac. ,BkPCfo trisny/te
OftrWORKERSCOMPE A ON DEC D!O 6 ORAa1 beroby affim undernalty of perjury ono of thA(eRowing declaration: Xhoe and will roubuain aCeAfict m ofConmm to self-insure for Workers Compel- JJ
7C3173'
on,uprovided for by Section J]W of Ne Labor Code,for Ne performance of the
rk for which Nis permit Is Inued.
hove and will mainWn Workers Compensation Irtuuencc,as required by Section
W of Ne labor Code,for the performance of Ne work fo which Nis permit Is issued.
y Workers CompenuUon Insuonce canto and Policy number are:
ller. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Trissection red nos bo cam pleted if the pe rm I t Is fo one hundm i dal Ian($100)
or leas)
I certify that in the Performance of the work for which this permit ensued,I fish nm
employ any person in my manncran as m become subject utile Worle s'Compensation
Laws of California.Date -
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificale of Exemption,you should
become subject in the Worker's Compensation provisions of the Lehr Code,you must
.J O forthwith comply with such provisions o Nis permll shall be deemed invoked.
z CONSTRUCTION LENDING AGENCY
y
[-v I hereby affirm that Vert is a eomuuctinn lending agency for Ne Neformmm of
the wort for which mm Permit Is intend(Scc.7097.Ci,C.)
0 Lenders Name
Z buiWen Address
U0 I anify Nn I have read this application and eau Nu the dim.Information is
rca Iagr
w .aee m comply with all city and county ordinances and man laws relating,to
building construction,prq and hereby auNon p representatives of this city to coos upon Nc
W
Above-(We)agre to property(memnify an Iseep hl
(We)agree m an.indemnify and hien hamlets the City of Cupons,s against
y in Cmsommum or theeoumd ex phis looich may in any war merino againnssiOCity
fJ 7 APPLIC'NT ND RSTANDSmil of A pemlL
•^+ APPLIC NT UNDERSTANDS AND OMPLY WITH ALL NON-POINT Issued by:91(2�&o Date
SDURC REGULA NS.
1 z� 3�K o Re-roofs
nuurc afnppl cmVc:nv 'rc -Type of Roof
HAZAR SM TERIALS DISCLOSU0.
Will the applicant of future Wilding occupant nom or handle hass dous material
as defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
ode.Sees.M32(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yos No
WIII the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
north havardous air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes No
I haveread she haraNnusmaterialsmquiremcnts unJerChapter6.95 of the Califo-
nisFWlthBSafety ode,Seedou 25505.25555and25554.IundergmWNuifdc building
d¢a not cornu aro a wnanL Nat it u my, mihility to notify the occupant of the
mquimmgnu arjnu rot tf.Certificateofampmer. Signature of Applicant Date
water to aohon.dl ogC.i ase All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
aCITY0
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADD • /f G �im�O Sc PERMYY#
OWNER'S N PHONE # 6 o? p&
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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 Signature Date
CITY OF CUPERTINOr L , S�0
+ FURNACE/AC 0 [ I
2 UPERTINO PERMIT APPLICATION FORM
APN# F rQ Date:
Building Address: 14
//J
rn
Owner' Name: d Ph a#:
/ /a Ao "a D
Contra or: �y Phone: G License#:
b 7�3 /
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ PjWnb ❑ Mech ❑
Job Description: C �-
Residential ❑ Commercial
For Residential Installations:
Attic ❑ 151 floor ❑ 2"d floor❑
dhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of!?t: 39� Type of Constructi n Occupancy group:
Strapped On Platform LJ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lace nt ❑
Qty, if
A blq Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BRENIAIRHAN A/C Units <= 10, 000 c&n MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMTI'FEE 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
$ �� � �