03060038 CITY OF CUPERTINO �' '"malas'm'^ ,`;44*aw"'N""„"`'4ww^^ 'te'`''a'
BUILDING DIVISION PERMIT CON:CRACTQRINFURMATIQN '
RUILDENGADDRESS: A PERFECT CLIMATE PERMIT N003060038
21721 SANTA BELLA PL
OWNER'S NAME: 10570 S DEANZA BLVD : PERMIT' 'j''l74/2003
'OBERT SHINAGAWA
NE: 861-9545 SANTPARY NO. CONTROL NO.
ARCHMIC'VENGINEER: BUILDING PERMIT INTO
BLDG EIFLT PLUMB MECH
0 0 � l�
.foZLICENSED CONTRACTOR'S DECLARATION Job Description
Mti� 1 hemby arr m than 1 me Ilam ni unser provisions of Chapter 9(Commencing p
whh Scrlan 7WU Tivison7o(tm Bmirmu tib fesdans o am aryl mends
<�q Ing tome and I VAC
t q j< Licenan a Lk.N
n Dam Contractor
ARCHTIEC75 DECLARATKEW[14
�i I undershoot my plans shall he used u public records �aY4AN y , �
3 Licensed Profcaimmt
OWNER-BUILDER DECLARATION (� O floo3
1 hereby ofliml the,I em eumpt from the CcOnommfs License law far Ne J IL l! L
o O following moon.(Section 713 L5,Bu,neas and Professions Cade:Any city of county
2 which requires a permit m eonsvuet alma Improw,demolish,or repair my structure
prior to its issuance,also requees the applicant for such permit to fileuignedwocrund C�ODI
_< Met be is liaosed pursuant to the previsions of Ne Contractor's license taw(Chaim,9 Sq.Ft.Floor Area Q
F$ (commencing with Section 7M)of Division 7 of the Business and Professions Code)or 6g
that be h exempt dmaefrom and the buts for dm alleged eumpdon.Any violation of
Section 7071.5 by any applicant for a permit anbjats the applicant to a civil penalty of V�eru U Occupancy Type
nm mom Nan five bundood dollars(SSW).
0 1,as owner of the property,ar my employees with wages u Nen sok compensation,
will do the work,and the nrorure Is not inmoded or offered for sok(Sec.704/,Bulinus
and Pro laxod a Cade:The Commerce,License law dos Mr apply to an owner of 303 - ROUGH eons
Property who builds Or impmtes tartan,and who dmsamh work himalfor through his 304 - ROUGH ELECTRICAL
own employees,pmened Mause
och Improvements e not Intended or Offered ferule IL
hewever,the building or improvement Is mid within one year ofcompledon,the owner- 501 — FINAL ELECTRICAL ENERGY
builder will low the burden of proving that he did not build or Improve for purpose of
aka). 502 - FINAL PLUMBING ENERGY
0 I.as owner of the property,am exclusively convecting with licensed anmsetors or 503 - FINAL MECHANICAL ENERGY
convect the project(SOe.7(144,Business and Professions Code:)The Cumnemes U-
room Law does not apply to an mcner or property who Wilds or Improws Memon.and, 505 — FINAL ELECTRICAL
who convects for such projects with a eanmctor(0 licensed pursuant W Me Caamarrea 507 - FINAL PLUMBING
License law.
0 l un exempt under See ,B A,P C for this meson 508 - FINAL MECHANICAL
weer Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under peaity of perjury ON Of the following doclamlau:
E[haw and will maintain a Certificate of Cogent to se16W um fw WOraeb Compen-
uon,as provided for by Section 7700 of the labor Code,for the performance of to
we for which this permit is Issued.
I haw and will myntun Workeh Compensation Insurance.as required by Secuan
W of Me labor Code,for the performance of me work for which this permit is issued,
M o Com enado nsuance arir and Policy n rye q -�
Ca, . 1 Polley No.: /T '✓���iY
C R WICATE OF EKEMPIION FROM WO KERS
COMPENSATION INSURANCE
(Thvuction mod nolbecomplemd If the permit Isforonc hundreddollan,(SIM)
or less.)
1 cenify Net in the performance Of the wort far which this permit is issued.I shall not
employ any person in my manner an u u become subject o Ne Warkeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenifiam of Exemption,you should
become subject to the Wort Compensation previsions of the labor Code.you must
.J Q forthwith comply with such provisions or this Permit shall be deemed revoked.
'Z ti CONSBUCr10N LENDING AGENCY
'[r I hereby arrive that mem is a convection lending agency for the Performance of
p:> the work for which this permit b issued(Sec.7W7,Civ.C.)
W Q Ludees Nurse
z Lcodcr'sAddma
[)z I certify that I haw mad this application and sum that de show information is
IA F correct.I agree m comply with all city and county ordinances and stsm laws relating m
O V Wilding consweton.and hereby mthoda¢pmaenuuves of this city m enter upon Ne
above-mcrumul property for Inspection purPOWL
W
Ff+W (We)agree to ave,indemnify and kap harmless Ne City of Cupertino agaiut t
CL Itsbiliuu,j menm, osuadeapenseswhichmayinanyway4ameapiuunid Ctry
V Z to c'itz cot ranting of this permit
�' APPLIC IN ANDS AND WILL COMPLY WITH AL NON-POINT Issued by: Date
SOURC U N .
Re-roofs
Sibmin plicwn D e of Roof
HAZA -thMATERIALSDISCLOSURB Type
Jl dm applicantor turebulldin6 occupantsmro orhandle huaAous material
u defined by the Cupenlno mode"o,Code.tluro,9.11.and the Health and Safety
viae.Seetieus72(a)7
u
YAll roofs shall be inspected prior to any roofing material being installed.
❑ I a
Will thc applicant o ing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Pmol hua,dnu air conumin u u 0ncd by the Bay Ama Air Quality Management all new materials for inspection.
Dismict7
0 Yu
I have read the bma dnusmaterlels requirements under Chapmr6.95 of the Calilm, _
nim Hcalth,k Safety Cade,Sommes25505,27577 and 25574.1 undersuM thatifde building
Joeyt.d'2.,hhd,fd
ew a Inner Nett n my reaponshiloy M notify scup t of the
myuim:t xmrpda,toiaaenaafacrdecam 0, ey� Signature of Applicant Date
own agent n mI� ) All roof coverings to be Class"B"or better
t I% CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN#
Buildin* Address: 1 1l U
OMs
Os G G Pllone#:
ntractor: Lige{�se�#'�� C
Confact: Cupertino Busi ess_License #:
Building Permit Info:
/Y�/
Bldg ❑ lect 4um ech--
Job Description:
Residential Commercial ❑
For Residential Installations:
Attie ❑ Is` floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
- S a Calc ations re ired for new installation ❑
,Kew installation Planning roval Required
Cost,4p;w'e Type C �'ction: Occupancy group:
'11trapped latform LJ Bonded LJ Sq.Ft. FI or Area:
New Location ❑ Replacement
Qty. if
App cal Fee ID Fee Description Fee Group
BENERGY Energ 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
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