03090247 CITY OF CUPER'fINO 771 , All m 7 '3•
BUILDING DIVISION PERMIT ,CONTRACTOR INFORMATION
BUI LDING ADDRESS: A PERFECT CLIMATE PERMIT NO 03090247
OWNER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
DAN MEYSERG n L30/200-3
lin
E: (408) 861-9545 SANITARY NO. CONTROL NO.
1TECTlENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0LICENSED CONTRACTORS DECLARATION
1 1 hereby affirm Nat 1 am licensed under previsions of Chapin 9(commencing Job Description
ction7001 fDividonJof the Ousiness end Profcuinn Code. rad ory,mr.is
Anse and r EPLACE FU CI� & ADD A/C
i License LM.N
i l•�
Dam Clnlnctor r
¢¢ A CHIT rSDECLA'RAVON
2 U I understand my plans shell W used as public records -
C� Licensed Professianel D
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3
OWNER-BUILDER DECLARATION
i i g I hereby affirm that I am exempt from the C - Lic�(Y��c Kfor IW
•
00 following mason.(Section 7(171.5,Business an , App cilY county r "'
Q$ which requires a permit m cnnsvucL strep Imp e,Jcmnlixh. rep it anyisof` f
prior to its loan..,alus requires Nc aPPlicenl fo ch person Sufi "P ligned salcmcnl
SS`o Nathcisliccnsedpunuantmthe prnvislonnfN 'eLicc pAw(cE�e�sous _ q.Ft. Floor Area Valuation
2 $ (commencing with Section 70M)nt Divtsion3nf t near and fe ' sCbde).1
]] that he is exempt Imminent and Um buts for Nee ed exern I A�n �q a of 3623 0094 . 00
Section 7031.5 by a"applicant(or permit subjec ea aeon Penalty of APN Number Occupancy Type
not more Nan Eve hundred dollen p y yP
❑1,As owner of the property,or my employees with wages As their mle compensation,
will do the work,and the structure is not intended or offend for sale 7044,Business 3ul — Kuuuki CIIO Its
end Pmfeaimu Code:The Conlnnoe,Lim.Law does nal apply to an owner of 303 - ROUGH M CHANT
AL
prepeny who Wilda or improves Nes Su
emon,and who doch work himselier through his
own employees,provided EPA uch improvements Are not Intended or offered for ale.If. 3O4 — ROUGH ELECTRICAL
hrxeer.the building or improvement is sold within ore year of completion,the owner.
Wilder wall have the Wrumn of proving Nat he did not Wild m im prose for purpose of 505 - FINAL ELECTRICAL
ale')' 507 - FINAL PLUMBING
❑1,a owner of the property,am exclusively contracting with licensed Contractors to
constrect the project(Sec.7W4,Business and Procession Code:)The Contractor's U. 508 — FINAL MECHANICAL
cense Law does not apply M an owner of property who Wilds or improves Nemon,and
Who mmumas for such projects with a contractor(,)licensed pursuant in the Contractors
License Law.
❑I am exempt under Sea .B At P C for this mann
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following Commuters:
1 hive unit will maintain a Certificate of Consent to ulGlaum for Worker's Compen-
sation,As provided for by Section 3700 of me Labor Code.for the performance of the
we for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,As required by Section
J of Nc labor CWo,for the performance of the work for which this permit is issued.
My orkcY�/p/rep, at urs/ e e r and Policy numbs
Carrier. !'I /fes Policy Ne: /7H
CERTIFICATE OF EXFbfPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not W completed Irihe Permit is for one hundred dellan(SIM)
or thss.)
1 certify that in Ne performance of the work for which this Permit u issued.I shall not
employ any person in any manner an As to WCorre subject o tM Workeri C.mpersadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:V.after makIng mu OuRricate of Exemption.you mould
become subject to the Worker's Compensation provisions of due Labor Code,you most
O foMwith comply with Such provision or this permit mall W occurred revoked.
Z�y CONSTRUCTION LENDING AGENCY
I hereby,frim that there ie•construction lending agency fm IW reffurrrence of
Yi ti tie,work for which this permit la issued(Sec.3097,Civ.C.)
Q Lender's Name
7 z lenders Add.
Q I certify Nn 1 have read this application mol sum duet the throw information is
y correct.1 Agree to comply with all city ad county ordinances and sum law,relating to
0U building Conswction,and hereby authorize represenmives of this city to encu upon the
4 above-mentioned property for lnsPection pugwfes
(We)Agree to ave,indemnify and keep hum less the City of Cupertino against
tifq IPthili0cs.judgment o,ts And..prouse,which to in any way game against aid City
J 7 in congy�EN
rte• APPLICIL P ITH AIssued by; Date
Re-roofs
ore ofA icanUCmm
OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcupant.tom cur handle hazardous material
As defined by the Cupenino Municipal Code.Chapter 9.13,and the Health and Safety
Code.Scelen 25532(.)?
❑Yrs 01V All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or ulune buildi occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haardnus air contaminants a def cd by the Bay Arca Air Quality Management all new materials for inspection.
inrtm?
❑Ycs
Ihamreuldmbaardlw ,501;3 yviremenu under Chmpter695.f Ne Glifor
ria Heslin Safety Earn
75505. JJ and2S5N.l undcnuM W iflM Willing
docs not currcmty bens c nL unit i y rcapomibility w wtifY Ih CoVP t of drc
requirements whit a me p' uiud a cerd0r Signature of Applicant Date
D manth gent Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
FURNACE/AC �j`'� 6 2-17
' CUPERTINO PERMIT APPLICATION FORM
APN # ZCPa 3bZ) Date: ,\ 3
Building Address: —7571 a, S had e k-kA1` ` A" V
Owner's Name: Mel/b J Phone#:C I Ig In _ 3�a
CongJ�ra Phone LACO License#�
SConY l SYS-
Con
act: hone: Cupertino Business License#:
I «c5
Building Permit'Info:
Bldg ❑ Elect V Plumb ❑ Mech
Job Description: &V Iuu G\.
Residential Commercial ❑
For Rggidential I ilations:
Attic u 1"floor LJ 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Project: rJ a Type f Construction: Oc upancy group:
Strapped ❑ On Platform U Bonded LJ Sq.Ft. Moor Area:
New Location ❑ Re lacementzK
Qty. if
AppliFee 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
EPERMTTFEE 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