05020125 CITY OF CUPERTINO ' a ' a ar .
BUILDING DIVISION PERMITC01�bT�C"TOR�I,1�`CIRMATI, ,
BUILDING ADDRESS: A PERFECT CLIMATE PEIIMIT NOO 5020125
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY CONTROL NO.
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=
il8 LICENSED CONTRACTOR'S DECLARATION Job Descri UOD
it F 1 Mmby affirm that 1 am licensed under pmvislom of Chapter 9(commencing p
cis with Sermon 7M)ofDivvisim 3 of to Ron.and Pmfesaio+u Code.and my license is
km.ll Class Berra 23/S8 REPLACE 2 FURNACES-ADD A/C (2)
]r{? Damm Class Lic.Y
Dam Contractor. a
ARCHITECT'S DECLARATI
I understand my plan shall W used as public record,
SQ Licensed Professional
OWNER.BUILDER DECLARATION
+� I hereby effbm that I am sump,from the Contractor's License Law for the
00 following mason.(Sation 7031.5,Business and Professions Cads:Any city or county
9 which requires a Permit to consumer,eller.Improve,demolish,or repair any me um
�^ prior m its issuance.also requires to applicant for such permit m rile a signed statement
t�< that he is licensed pursuant in the provislom of the ConmcmYWcense Law(Chapter 9 Sq. Ft. Floor Area Valuation
^`d � (eamenncingwith Sation7ODO)afDlvmiea3af Ur.Busi.,nd Pmrmiom CN)or
du,Ire u mmpl tMmfrom and the basis for the alleged exemption.Any viola0on of 826000
Section 7031.5 by any applicant for a permit mb)ecta the applmml to a civil penalty of APN Number Occupancy
Trot mom Nm five hundred dollars(55001 p y Type
o T,umworN pmpmy,mmyempleymwithwagexu0eirmlecempemom, f! l9 fY
will do the wurkmm theaumctum u not Intended oroRered fonam(Sm.7044,Sulneu o 'a�tlt.n a
and Pmfes lwhore Cede:The CmmcroYs L item law dem rot appy to an owner of Required Inspe ons ^®
property wbulldsorimpmvn theron.and whodoessuch work himselfor through his V
own employees,provided Nat such improvements am not Intended meRerecd for vie,If.
hmvevm.the building or Improvement Is sold within oro year of er mpleden,the evect.
Wilder will have the burden of proving that he did net Wild or improve for purpose of
sale.).
❑1,a owner of the property,am exclusively Conncting with licensed contnemn m �r r•J
construct the project(Sec.7014,Business and Pmrrssiem Cede:)The Contramor's U. yp
cam Law dose not an owner ep proms(who Wade or improve becomes. k
eon,and �/, ,q l
who contracts for uch projects;cwiNeeonuacmr(a)licensed pursuant mtM ConmacmYs
License law.
❑1 am exempt under gee. .B A P C far this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby,rein under penalty of perjury,one of the following declarations:
1 h,w:and will mainW n aCenifiam of Comm¢self-ileum ria Worhfs Compen-
ation,a provided for by Section 37M of the Labor Code.for the Performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compemden Insurance,u required by Section
37M of the label Code,for the performance of the work for which this Permit is Wad.
My Worke\r's,,C-emremadon Insurance carrier and Policy number sec:
Carrier. sf v/k-9 R,I,IFI�p EMpnPoiiey No.:A 1 R 11��
ON FROM WORKER
COMPENSATION INSURANCE
Crim semis need notMcempleted lithe permit Is fmonehund+ed dollars(SIM)
or kis.)
1 crify that in the performance of the work for which this Permit is Issued,I shall not
employ any person in any manner m as in become subject to IN Workers'Compemadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
baome subjm in the Workers Compensation Pm mom of the Lx m Code.you mum
.J O foMwith comply with such provision or this permil shell W deemed revoked.
,z.s t•" CONSTRUCTION LENDING AGENCY
F work
hi
hthilion,that them beamSec.3 lending agency for Nu performance of
�i ti the wort Tar which Nle parol,m issued(Sec.3097,Civ.C.)
GLender's Name
Z Landers Address
VQ I comfy Nut have role thishorrm rprsedetave that the above enter
nise
U eorteeLIarramcomply Wilall is application
andaWn and
and aum laws relatingm
0 LTJ^ Wove-ammsmcliogand hereby amhorizereoses,representatives of this city to cnmr upon lc
W above-mentioned propertysave for Inspection purposes,
(We)agora to sea,indemnify"I'll harmle City o(Cupenino against
i..�T/3 Ilabilhlm.judgments,eon mdapcma which may m ymcrue,Pim,WdCiry
V F77 In conxqueneeo d` grmtinB oflis Permi4
APPLICANT U DER ANDS AND WILeonz
TH ALL NON-POINT Issued by: Date
SOURCE REC TI
Re-roofs
Si of AteplianYConuuror Dam ,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant seam ev handle haallon material
in derncd by he Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
ode,
S-'".
e Oyu2ss3z(a)7 All roofs shall be inspected nor to an roofing material beim
❑Yu - No p p Y B g installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I Wrardom air conmelmnm u defined by the Bay Area Air Qualily Management all new materials for inspection.
ulet? —/
❑Ya e
Us ave red the hauadaus nowrialsrequiremenu under Chapmr6.95 orthe Collier.
nia Hcalth@safety Coda Sectiom25S05,25W=21 untlemmndthatifte Wilding
does not c rally ave a tenana that i,' mipomihilily m notify the oceupant of the
requireme w m.in hemetdor ua(r f.Ccmreemoraapancy. Signature of Applicant Date
_ `"-- 2 �� C5 All roof coverings to be Class "B"or better
Owner or authorized agent Dam g
Community Development
Torte Avenue
` C p Oertino A 9 014
Telephone(408) 777-3228
cl o Fax(408)777-3333
�PEkTINO
Building Department
JOB ADDRESS:!7 a PERMIT # OS�U Z o( ZsI
OWNER'S NAME: Tmoy
PHONE # $ —
GENERAL CONTR OR FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electricali �3
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
IMF Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
2 , 17 65
Owner/Contractor Signa a Date
CITY OF CUPERTINO
D1' FURNACE/AC
CnOF
UPERTINO PERMIT APPLICATION FORM
APN # Date:
-a l7.OS
Building Address:
LrL
Owner's Name: T Phone #:
o tor: t Phone: License#:
Contact: Phone: Cupertino Business icense#:
7";e-
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description*
ResidentialV�'1. _ Co ercial ❑
For Residential Installations: wbPC n`0
Attic ❑ 1" floor ❑ 2nd floor❑ -
dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑ — -- -
Structural Calculations required for new installation,. El .. r.,...d.. ..4.,
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: • -.-- ----- .Occupancy group:
6tsD --
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacerrientp
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN RFurnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAII2HAN A/C Units<= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING'
BSEISMICOM Seismic Commercial BUILIDNG
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING