03110123 CFry OF CUPER't'[NO 4 ' " '%`O
BUILDING DIVISION PERMIT VCONTRACTOR INFORMATION
BU I LDING ADDRESS: A PERFECT CLIMATE PERMITNO03110123
OWNER'S NAME: PERMIT ISSUE DATE
ISSON ED 11/2 2003
ONE: SANITARY NO. CONTROL NO.
(408 861-9545
ARCHITECT/ENGINEER: -BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� t�
30Zp LICENSED CONTRACTOR'S DECLARATION
£fiz I hemby.(Firm that l am licensed undo provision.Of Chapter 9(mmmencing lob Description -
v< with Section 7000 Division 3 of NC Business and Professions Co .andmylicenxie
mu(nre ana r REPLACE FURNACE AND ADD A/C
Lli is,ut as Lic.X
�t,p DyF! Cunlraefor
7W RCHMECT'S DECLARATION
f U I understand my plana shall he used as public records
a
s o
Licensed Professional
the I....am,, fr DECLARATION
F I hereby,(Sero once I.m exempt(rum the Comrenoh License Lew for the
p O following mama.(Section 7131.5,Businessandmpr improve,
de inns cola Any city or county
$ which requires a permit to construct,Aall,pplicant
improv,demolish,or repair any atmmre $8972
Pnonn its issuance,olsu mquims the arrPlic.nl for such Permiuo.file atigneJ sotemem
f$O that he islicensed punuu
anutheprovisionsOrtheContractoraLicenulsw(ChapterY Sq.Ft. Floor Area Valuation
5 G3 (commencing with Section 7")of Division J of the Business and Proresinna Ctdc)or
that M is exempt thereinto and the basis for the alleged exemption.Any vialadnn of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil pendty of 37AMRQ;1Tffiel00 Occupancy Type
not mom than Eve hundred dollen(5500). P Y YP
Lo owner .the pmperty,or intended
wlNwagd rdr..ei(Sm.c ,Buss less
will Pr fiffie won,end e:ffiermerare is not intendede I w does
sonata apply
t oan Business
and Prtywhobu coda:The improves
themore License Lw dee,or apply to an owner err Required Inspections
own eery who bailor or emphases thereon,end who Am not i h work himseRor though his
own employees,provior imprthat ovemsh ent
irovementa in not intended completioarofferedn,
for owner.
builder Nebuildingor improvement iehatheiiinoto year or completion,Ne awe of
builder will ties she burden of proving Nn he did not build or improv for purpose of C ®�
Aida.).
■ INAL
❑1,as owner of the property,,Business s and contacting with:)The
contractors t.
cause La the es not(Sec.7044,owner
fend Professions Ws Coo.:)The Codnor. d q
whoconwdoor such plytont with
whosedpds or improves Contractor's
DEC - 3'2003'
who contacts for projects with a convaaor(r)licensed pureuem m tk Comnnora ,
Licence la W.
❑l am exempt under S., ,B,k PCfor this mean
Owner Data BUILDING
WORKER'S COMPENSATION DECLARATION
1 hereby.(frrm under penalty of perjury mm of the following declarations:
1 hew and will maintain a Certificate of Consent to self-insum for Worlues Compcm
sal on,as provided for by Section 37IX1 of Ne Tabor Cade,for the Performance of Ne
for which Nia permit I.issued.
ave and will maintain Worker's Compensation Insurance,u required by Section
7700 c labor Code.ror the performance of the work for which this permit is issued.
My Workefs n real psurence c in land PO my numb/��a/q�f� rt
Cartier: oliayN..: �
IC MICT IFI ATE OFEXE PnON FROM WORKERS'
COMPENSATION INSURANCE
oils sedinn need not hecomplened If the Permit Is fnrom hundred dollen($100)
less.)
1 eenify that in the performenec of the work for which this permit it issued;I shall not
employ any person in any manner an as m become subject to the Workeri'Cnmpemation
Laws of Calif Brox Data
Applicant
NOTICE TO APPLICANT:IL after making this Cerirmam of Exemption,you should
become subject to the Worker's Compensation Pmviaions of the Labor Code,you must
�O fonhwith campy with such Pntvainns err this Permit hall be decmcd rtv.k,d.
Z^ CONSTRUCTION LENDING AGENCY
I hereby anion that Nem its eonsuuninn lending agency for the performance of
'y. floc work fur which this permit is issued(Sec.3097,Co.C.)
131 Q Lando',Nora
Z Lender's Address
U C 1 certify that 1 have mad this application and sole that Ne above infontatiun is
momL I agree to comply with all city and county uNinances and state laws relating to
sem. building construction,and hereby authodae mPrexnotivu of Nis city to cneruprt the
W dhow-mentioned Pmrarty for inspection purposes.
gy (We)agree to save,indemnify and keep harmlem the City of Cupertino against l s
y liabilities,judgments nand expenses which may in any way accrue against mid City
Uz in conseyucncea ranting are 't.
APPLICA N ERST S AND W L COMPLY WI L N NPO Issued by: Date
SOUR GU TIO f.
e-roofs
Signature
or p canUConmmor Date
HAZARDOUS MATE DISCLOSURE ype of Roof
Will Use applicant or future building Occurrent store or handle hazardous mations)
As deflued by the Cupertino Municipal Code,Chapter 9.17,end the Health and Safety
Ini.
M, Oyu zss3x.r All roofs shall be inspected nor to an roofing material being❑Yea P P Y g g installed.
% Ll the applicant or rut aabaildl current ax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous i,mot inanu a y0m Bay Arca Air Quality Management all new materials for inspection.
❑Yes
I have real Ne hzanlnus materials regre nu under Chapter 695 or the Cali foo-Hanlon gE Safety Code,Sections 25505.25573 tad 25534.1 timmarond that iftM building
s not cunenlly how a one atit BmyresWmihilitymnodfythemcuPmtofthe
uirc ts which must M t pnun 'suancc of a Cc of Occu
6/ Signature of Applicant Date
own., d m Data All roof coverings to be Class•'B" or better
0 / Z3
CITY OF CUPERTINO
oz
C.t% FURNACE/AC l
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# 3 7S D!::;- i,51 J Date:
Building Address:
Owner's Name
2
Contractorho Li e_nse#:
L
Contact: r I Phone: Cup e 'n Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description: �2n,,.,l QCT vv � CA/-Ao a ,j -t64C
Residential , w Commercial ❑
For Ree�ssidential nL llations:
Attic LJ I"floor 2nd floor❑
r� Adhere to min set back requirement❑
C� For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Coofloject;_ �- Type f o-s ction: O upancy rou
Stra ped LJ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area: �n n
New Location ❑ Replacement ❑ tv '
Qty. if
A bk Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
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
EPERMrrFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMrrFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business Licen BUILDING