04070127 CITY OF CUPERTINO C01�1TRA.CTORINO'CtMATI01
BUILDING DIV PERMIT �,,.,, ,n„p y , n m. '� ^:
PERMIT NO.
BUILDING ADDRESS: A PERFECT CLIMATE 04070127
PERMIT LSUE DATE
OWNER'S NAME:
SANITARY 3:112OL NO.
ONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG EO PLO O
B spm LICENSED CONfRAC10R'S DECLARATION Job Description
'yM b p I hereby"B'”Thal Its'
am licomod under provisions of Chapter 9(commencing /
^� wilhsauan]IXIO)ofoiviaian Sof Ne Businrssand Profession Code,ntd mylicense is �/
In full fome.ad eRem. NEW GAS FURNACE
5�z Licence Clea Lk.M
^
DOW-
m ARCHITbeused public old& z7/may f,�
1 understand my plans shell M used a public reenNa 'V
3 a
Licensed Pndmsional
y0 Met
DECLARATION
X10 I hereby arTum o n 1 am.Burin from the f asimut Cal:Any c Uw for be
my
m 4 which
coving meson.(ohm,i Eommm,,.fines.and Pofdt oll Code:Any city car canny
q which rtyulrm a penmen m¢newel,alms impmw,dcmnllah,or¢pair any shunts¢
that
p,alsumquithe provisions
o foe Commutes
Laedanmmem S Ft.Floor Area Valuat on
�pp x�xi Nen he is licensed pursuant to theepmvivisionf Ne Contractors License law(Chapterode)., Q•
yF$ (mournaing with Section]0007 of Division the Busincaond Professions Code)a
Nat k 4 sampt Nemfrom and the ba4 fm.d alleged caempdon.Any vioiallon of 3 JO D�N0mtA7I�O Occupancy Type
Section 7031.5 by any applicant fora permit subjects Ne appImML to a civil penalty of
on,mom than five hundred dollars($500). "
L u owner of Jon property,as my employ=with wages as lhe4 role compenalmn,
willdo the work,and Ne amo uts is not immoded orolfesed forsale(Sm.7044,Business Required Inspections
and Pmfessiem Cade:The Connector's Lieeme Law docs r at apply m an owner of
"Pan,who Wildsmimp.Nerma.andwho doe.auchwodthimmlf ortiuough his
awn employ=,provided that such Improw scam arc not intended uroRered for sale.If.
however,the building or Improvement 4 sold within am year of mmpkdon,the owner-
builder will have Ne burden of pmving that he did not build or improve fm purpose of
as owner of the pmpeny,sue mu lmiwly consacting with licensed mnwcmn to
construct Ne projem(sec.7814,Business and Pmi lain.Code)The Conusmra V-
cents law docs oat apply to enowner of pmpeny who builds or improves themun,and,
.1mem rmisforsuch projecu tui or(U licensed pursuantodm Crenrantora
Lkcnse Law.
[3 1 sue exempt m. ,BAPCf0, is re n
O Dam
WORKER'S COMPENSAT N LARATION
I hereby slfsrenundar Pemlty of Padu a of Je rallowi dalantiom:
I have and will maintain aCertlOeemof Co nnosel6botonfor Workcra Compere
Jon,so provided for by Section 3700 of the r Code.for the performance or the
work for which this permit is issued.
❑1 have and will maimain Workers Compensation hentomm.a required by section .
37W of Ne labor Code.rue the performance or Ne work for which mis permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS' ,
COMPENSATION INSURANCE
(This section need not he Wroplemd if the PermiUs Immus hundmddollan(5100)
ser I....)
I certify Nat in to Performance of Ne wells rot which this Permit'a issued,l shall not
employ any person in any manner so as to became subject o me WOrkcW Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL sites making Nis Cenificam of Exemption,you should
become subject M Ne Worker's Compensation provisions of Ne Lehr Code,you Most
,J x forthwith amply with such provisions or this permit shell be deemed¢voted.
ti C CONSTRUCTION LENDING AGENCY -
[tiIhemby afasm Nat there is a cocanderion lending agency for Ne"fornamoca
yv r7 Nc work fur which this permit 4 issued(Sec.3M,Civ.C.)
W Lander':Name
a Lenders Address
V I cenify ren 1 have read this application and sum Net me shove informatiun is
W;-+ correct.I agues to comply with all city and county on inams and sum laws misting to
[V^ building conawcdon,and hereby auNoris rtprmenuai rs of this rocnmrvpnn Ne
abovomentioned iormny for Inspection purposes.
Fa (We).gme to saw.indemnify and keep harmless me City of Cupertino ag.imt
fA liabilidu,judgmcnu nem which may in say way accrue against said City
V7 in comeque cgnmingoftht permit. e
^. APP UNDERSTANDS A DWI L COMPLY WITH NON- INT Issued by:
CE REGULATIONS. C> L,
Re-roofs
S' urtofApplianUCanuacmr am of Roof
HAZARDOUSM ERIALS DISCLOS E Type
Will Ncapid an,ser future Jing necupant atom or lunde hu4Nous material
az droned by the Cupertino Muni al Cadc,Chapmr 9.13.ad Ilse Health and Safely
Cole,scc0on 3553Xa)7 dNe' All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will Ne applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, agree to remove
mit haamnm air contaminants as dcAsoul by the Bay Arca Air Quality Management all new materials for Inspection.
iWict?
❑Yes
the ehvasdousmam'Is mquimmenb under Chepter6.95oftheCxllfor-
hiaHc Safety Cade,Scetions2550.35533 J3l53 Iumkntad thatifthcya'ding
.at cumemly he a¢Hens Nm i my pansihillty m notify 'cupan f the
requirements which¢tits lcm 1pdar s rar.ccnifjeg ppay 0 Signature of Applicant Date
f/ All roof coverings to be Class"B"or better
tuner or.whomcd agent am
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Cl OF Fax(408)777-3333
JTINOUPEk
Building Department
J
' �A D E PERMIT#
D D/2
OWNER'S NAME. G PHOIX #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
G Glass/ Glazing
Heating LG//red rG`
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Da �/
`J Owner/ ct igna a Date
�0
t
CITY OF CUPERTINO
FURNACE/AC o 2 �.
�UPCITYEI�TINO PERMIT APPLICATION FORM
IN # 36Y_ 3 ,,Z , 0� Date:
Building Address
qP /si°Tv6 G,�i�E
Owner' xlv- ,i ee P n #'
s Nam ,,2,S5 1'
C/Jtra/°izFELT Gu/f--76 Ph
d ��i�9�/1"v License#za
Contac5v PhAn D� ` i Cupertino7Business License #:
Building Permit Info: L J
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descri tion:
/,Vs�,4 LL a-'6-5 ui�•tI.AG� X//
Residential 21 Commercial ❑
For Residential In� ,stflAtions:
Attic ❑ I't floor V 2"a floor❑
dhere to min set back requirement❑
or Commercial Installations:
Replacement same weight E] Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installati lannin A ro uired El
Cost of P15." �'� hype of Cons c i Occupancy oup
Strapped On Platform ❑ Bonded LJ Sq.Ft. Floor
New Location ElRe Replacement
Qty. if
A li Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BRENU URN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIItHAN A/C Units <= 10, 000 cfin MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
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 Licens BUILDING