03070152 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT"03070152
0 -A.
R'TNAM E7------- PERMIT ISSUE DAM;ikz TcwlT
10570 S DEANZA BLVD
RAT.PW CUAR172Y
ONE: (408) 861-9545 SANITARY O. CONTROL NO,
f
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG MISCH
nix, tf pn
�0, LICENSED CONTRACTOR'S DECLARATION
UW� I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
wife Second 7000)of Division 3 of Ne Business and Professions Code,and my license is
-eeo, in lull force no
z LiemesC , --- I
Lic.# I _ REPLACE FURNACE
Contractor PINALWO
A HITECTS DECLAR_Aft_03V'neRq
D�u
1 untlerstand my plans shall he used as puM1lic mmNx
x:81- JAN 13 2004
Licensed P..[dieumod
OWNER-BUILDER DECLARATION
I hereby topern
he,I am exempt from the Contractor's License Law for the
n 0 following rcasnn.(Section
7031.5,Business,and NoNishons Code;Any city or county
which requires it pedamt In construct,alter,improve,demolish,or repair any structure
Fxi prior to its issmance,also requires the applicant forsuch Permit totile a signeditatement 9�2
thin he is licensed pursuant to the previsions of the Contractor's Liame Law(Chapter 9 Sq.Ft. Floor Area Valuation-
di (commencing with Section 7")of Division 3 of The Business and Professions Code)or
Nat he is exempt derefood and the basis for me.11i inumn,shm.A.,violation of 35C)l 4002 00
Section 7031.5 by any applicant for a permit subjects the applicant to R CIVH Penalty Of APN Number Occupancy Type
not..I.n five hundred dollars($501)).
0 1,m Owner of the property,or my employees with wages;ai their sale compensation,
ME&ftworic,and thaudiction,uninintended oroffered Russia(Sec.7044,Businen
and Professions Code;The Contractor's Lima.Law it=not apply to an Owner of 303 — ROUGH I s
property who builds or improves daemon,and who doessuch work himselfor through his 304 — ROUGH ELECTRICAL
man employees,provided that such improvements am not Intended in offered for sale.If,
however,the building or improvement is sold within on year of completion.the owner505 — FINAL ELECTRICAL
builder will haw the burden of proving that e not Wili
Wild or improve for purpose of
side.). hdid 508 — FINAL MECHANICAL
0 1.as Owner of the property,am exclusively contracting with licensed contractors to
commuct the project(see )044,Business and Professions Coda:)The Comment's Li.
came Law does not apply to an owner of property who Wilds or Improved;toomon.and
Who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
LicenseLaw.
0 1 am exempt under See, ,B&P C for this nodded
Owner Data
WORKER'S COMPENSATION-DECLARATION
I hereby affirm under Penalty or factory one of the billowing decimations:
I have and will Maintain.C(mirlesu.of Consent to salf-intim for Worker's Camped.
sm,sts provided for by Section 370 of she Ube,Code,for the performonex of 0r
work for which this Permit is issued.
have and will maintain Worker's Compensation Insurance,m requited by Section
3X of the Labor Code,for the performance of the work for which his Permit is issued.
1)v,
y Worker lion Insurance carrier and Policy number me-
Cut licy No.: AA-Cill"sli
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This samimmneed nil tacomphnedifthe permit is foronchundred dollars(SI W)
"Imu.)
I wrify that in the Performance of the work for which this Permit is issued,I shell not
employ any Person in any manner an as to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this C(onrimbe Of Exemption,you Should
become Subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply withsuch previsions or this Permit shut]he deemed resume.
z 0
55 CON STRUM ON LENDING AGENCY
1 hereby affirm thin Were is 8 Construction lending agency for the Performance of
the warts for which this Pennot is issued St 3097,Civ.Cd
QLender's Name
CL
=1 z Lender's Address
U 0 1 cenify that I have mad this application and marc that Ne above information is
D,,F Carmel,I 89MC to Comply With all city and county Ordinances and sDlc fow"eltaid,In
0U building construction.and hereby amomin representatives of this city to enter upon[he
above-mention Property for Inspection Purposes.
W
Pki (We) closaword nryend keep h�]eSSLhCCity ofCu�rtinoag at
liabilities ju ents,cosaia as rims which may in anyway accon,against said'in
Z in consedu colt grant if is permit.
City
APPLIC UN RST N AND WILL COMPLY WITH ALL TN-POINT Issued by:
S R R GU :0
4 Re-roofs
Signature Ap indo/C." I Wide/
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W I ."Jimin orfolum building occupantIran or handle hazardous innocent
ss defined the Cupertino Muriel a]Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)9
7 Ye. % All roofs shall be inspected prior to any roofing material being installed.
Will the applicant o
Tbuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it namodma, it .at. mants defined by the Buy Am.Air Oindity Management all new materials for inspection.
[3 Ya. N
Ib c mad It mord) sin hoos requirements under Chapter 6.95 of We Califor.
diuHrul safety c,See 5(15,25533add25534.Iimderx main dffi If building
ble,
does no -d rallywean I, at it is my responsibility to food I hic accutunt or the
,cq.i, en win s c(t or to issuance of a Did-u of
zI'Li Signature of Applicant Date
All roof coverings to be Class"B"or better
R
CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN# I, r Date: ^
1 I A-
B ildi
Buildin AddrI
Own Nalne: Phone#:
Con actor, 1 Lice
�� 15
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descrip '
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Struc ale 'ons equired for new installation ❑
Ne stallation PI g Approval Required
st Project: Type , f Construction: Occu cy group:
1n
Strappe On Platform Bonded Sq.Ft. Floor a:
ocation ❑ Re lacemen
Qty. if
Appli le Fee ID Fee Description Fee Group
BENERGY Ener 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