04110040 CITY OF CUPERTINO .. 4`?c'e�s�..rr�/ 7Opr �'" :�"'""`�a�,}`"♦` ` '
, BUILDING DI VISIONPERT. ... ,k�� lkllU' Rtit�1 .C.
BUILDI NO ADDRESS: PERMIT NO.
A PERFECT CLIMATE 04110040
PERMIT.ISSUE DATE
N SANITARY1'a 0 8 2 OZRFOL No.' _ .
ARCHTTECT/ENGINEER: - BUILDING PERMIT INFO
. BLDG" ELECT PLUMB MECH
�oZ LICENSED CONTRACTOR'S DECLARATION
�1 I rtby ell"m
the 1 am licenud under provisions of Chapter 9(Commencing Job DCSCrIpIIOn�
wnNsauo )of1=1,n3ofthc Businev,yetgofruios Code,and my licese is
:a is mgr ndoffke ✓./
Lm�nm C) oak tauter REPLACE FURNCAE & ADD A/C
q ARCHITECTS DEC ION air
22 I undcrwnd my plw))hall he tired u pub rccsds
i Licensed PoersJonel
OWNER-BUILDER DEC Contractor's
I hereby.(Sere on 1 em exempt from Ne Cantracm o License taw for rty
i o following mann.(Section 7 on L5,Business and improve.
de ios Code:Any city or county _ I
which requires a permit re ennswe',eller,improve,demolish,or repair ed tWaure
—i loiormiu issuance also requires the th)) inion of for such surmount OleaeLaw statement
Usi=< (commecing wit pumuant 7001))of Diamronr th. Cosmos dProrlaw(Chapmmv _ Sq.Ft..Floor Area Valu))
u�s�$ (commas exert merro70W)of,hicks n3 ofdm Bsineuandon,Any vi Cock)or _
W[he V eumpt Nertfrom and Ne buss fm do Jlcged exemption,Any violation of
Section 7031.5 by any applicant for a permit ubjuts the applicant to a civil penalty of her .Occupancy Type
not Conte Nen Tim hundred dollars($500). - 3 � O(]
I,In owner of the property,or my emplyass with wages u their))ole compensation,
will da the work.and the a4ucturt rano[inarmded oroffered forsah(Sec.70th,Business
and Propositions CoThe Canttacmrs ueenae Law it=not apply m an owner or Required Inspections
property who builds orimprowa themon,and who doe auc h work himulf ar through his
own employee,provided that such imp rommCut as tie not intended or a@ree for tile.If.
however.the Wilding or improvement is sold within one you of Completion,the Owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
tile.).
1,as Owner of the property,am exclusively contracting with licamied Contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U. .
mac law does not apply to an owner of property who Wilda or improves Merton,and
who contracts for such projects with a contractor(s)beenmd pursues to the Contncmfs _
License Lan-
❑lamexempt until,Sec. ,B h P C for this reason
Ownx Date
WORKER'S COM PEKSATION DECLARATION
1 hereby JRrm not,porosity of perjury os of the following declunlons:
x I him and will maintain A Cenlfieue of Consent to ml6isure for WarkefsCompen-
don.u provided for by Section 3700 of the labor Code,for the performance of tW
one for which this permit is issued.
and will maintain Workers Compensation Insurance,is requited by Section
NC MbarCode,for the performance of the work for which this permit is issued.
My Worke�fs/JCo�m�sa/u'yn�In�s�un/nm))Trier and Poliy num am:
Trier. rlJljlL1FIRTE OF C
ERTIFlC OMPE SA FROM WORKERS'
' COMPENSATION INSURANCE
(Thu.1.tied not W comPk¢d truss permit is for.hundred da11an(5100)
or loss.)
I unify Ne[in to perforator.of the work for which this permit is bible.I shall not
employ any person in any manner so u to become subjen to the Workers'CompensNnn .
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificme of Exemption,you should
become subject in lie Workm's Compensation previsions or the tabor Code,you must
.Jz forthwith comply with such provisions or this permit she]tic deemed rtvoked.
ZOCONSTRUCTION LENDING AGENCY
(r► Ihereby affirm lha[Nem is a construction lerningageney lot the perfortnan¢of
ai t7 the work Tor which this permit Is issued(Sec.3W7,Civ.C.) _
f+d Q Undoes Nam.
It, Iande,'s Addtea.
U O I c.ulfy that 1 have mad this application and stste that the own information is
F comca I agree to comply with all city and county oNiumes and sale law mining to
O V building construction,end hereby auNOnx repmsematima of this city m color upon dm
eb.m-mcndoncUl propony for ispecdan putposos.
l.
ty of
niu.against
ta/) liabilities judgments.costs and expenses which may in any waymaccsc gain mid City
(„)z in comer.,,e of dm granting of this permil
^ APPLI UN ERSTANDS AND WILL.COMPLY WITH ALL NON-POI Issued by: Date
SO U TIONS. \/
r Re-roofs
Signature of ApplicmVContncwr Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future Wilding occupm'store or handle hsrudous material
az earned by the Cupertino nine Code,Chapter 9,12,and the Health and Safety
cWe. C3 es 25632(.)7 All roofs shall be inspected prior to any roofing material being installed.
C3 yes NO
Will Nc applicant or future building occupant tax equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardru s air contaminants as de0sd by Ne Bay Area Air Quality Management all new materials for inspection.
ixtr1O7
❑Ys -
jt-1 have read the bar Nous motorists requirements under Chapter 6.95 of the Califor-
nia Hcal"SafctyCodc.Sections 25505.25533 end 25534. undenaM thus if the Wilding
dura nO[uurrent haw a nen',that it u my reponsidi noir))dm accupmt o9!f!
mquimemn h met '0T V..loom of t. .))pony. Ipplicant Date
Owncr rauNonredagent Data All roof coverings to be Class"B"or better
.� Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: I PERMIT # �1 I
OWNER'S NAME: t J ' PHONE # q'0--Q,
1 `l
GENERAL CONTRACT t FAAXX#
I am not using any subcontractors: L2 LLT 1! O
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
11
Owner/Contractor Signature Dat
CITY OF CUPERTINO
- oaf
UPERTINO PERMIT APPLICATION FORM
APN,# � Date:
Building Address: I mz `(
Owner's Name: 1 u !� Phone#:
Q. l/� l/1 C � `7 Ub
Contractor: hone: License #:r l 23( v�
Contact: Phone: IN
r Cupertino Business License #:
Building Permit Info: (�
Bldg ❑ Elect D]--� Plumb ❑ Mech E5---�
Job Description:
r�tc� ce_
Residential Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2°a floor ❑
Adhere to min setback requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: _ ` , Type of Construction: Occupancy group:
Strapped' ❑ On/-Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. 'f
A 1' abJl Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
111-27- BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
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 Licens BUILDING