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06080071 CITY OF CUPERTINO + q:?'i•s r> a f +`' WILDING DIVISION PERMIT 1 CONTRACTQR INk'QRMATION, BUILDING ADDRESS: AC SERVICE & DESIGN CO PERMITNO.06080071 22601 VOSS AVE OWNER'S NAME: PERMIT ISSUE DATE CITY OF CUPERTINO 5800 GILRO NE: SANITARY NO. CONTROL NO. (408) 842-1312 ARCHI3ERYENGTNEER: BUILDING PERMIT INFO BLDGELECT PLUMB MECH 0 0 0 0 loo LICENSED CONTRACTOR'S DECLARATION IOb Description w I hereby affirm Thal 1 am licensed under provisions of Clmptcr 9(commencing tJ iN Section?1)(lo)of Division 3ofdm Busiest and!Proteuium Code,and my license is ' HL(.11 crteandeffect REPLACE A/C UNIT OF. ROOF License Class lr�z 1. Lie.• Dam GOnlraebr 5f1/ ``•�y ARCHITECTS DECLARATION i I undersand my plans shall W used a public records Iu.G Licensed Professional D i OWNER-BUILDER DECLARATION i 1 hereby affirm Nos I am ext,mPt from dun Contractor's Liccnx Law for the :2C C following reason.(Sol 7113 LS,Business and Professions Code:Any city or county 5 m which mquires a permit to eonswcl.tlter,improve,dcrodird,or repair any structure $15000 prior w its issuance,also requires the applicant for such Permit to rile a signed casement < thallmoliccnxdpurtheru lWpmvisiansafOcCanlrocmrOLicrosxLaw(Chapmr9 Sq.Ft. Floor Area Valuation Fm (commencing with section 7000)of Division 3 of to Business and Profeusiom Coat)or Out he Is exempt therefrom and the baso for the alleged ea eopuon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r Occupancy Type not mom Nan five hundred dollars(S50M). ❑1,as owner of the pmperty,or my employees wise wages a Web xlecompewtion, will pr Oewort and the he C.haivnotintended arancluess of apply an,Baixss Required Inspections propand Professions Cade:The COnuuces Liam Law does not apply f an awns of q P own enywho Wildsvimpnrvesch improve who daysuchweled orcellm though his ownemployers,provided pr suchimprovementswitamnos intendedurolfered thefornam IL builder .Nebuildingorien ovematusoldwithinone year of improve the owe of builder will have IW burden of proving that he did not Wild or improve(or purpose of ale.). 1,as owner of the property,am exclusively contracting with licensed conmac ns;to muct the project(Sec.?Oa,Business and Pmressioa Cade:)The Cmarl U. cense Taw dais not apply to as awrur of property be Winds or improves thereon,and. who central for such projects with a conuanor(s)licensed pursuant w the Consul License law. ❑ lam der See �.�/ ,B&PClorthismaon Ower /�C/ Dau WORKER'S COMPENSATION DECLARATION 1 thereby Nmt under penalty of perjury one of the following declarations: I ban and will maintain a Certificate of Conscre m self-insum far Warkcfs Carl sation.u provided for by Section 370 of the labor Cade,far the perform.of the - work for which this permit is issued. ❑1 have and will maintain Warkcts Compensation Insurance,a required by Section 3700 of the Labor Code.far We perrooll of the mil far which Nis Permit is issued. My Worker's Compensation Insurance carrier and Policy number art: Cartier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (ITU scctim need not W completed if the permit is Intent,hundred dollars(5100) or less) 1 certify that in the performance of the were for which this Permit u issued.l shall not employ any person in any u become subject m We Worlreri Compensation Laws or California.Dam --✓ / Applicant C NOTICE TO APPLICANT.IL afar making Wu Certificate of Exemption,you should become subject to the Workeh Compcnsedan provisions of We Labor Codc,you most .0 O forthwith comply with such provisions m this permit shall W deemed reveled. Z` CONSTRUCTION LENDING AGENCY (•"� I hereby affirm that Were iso construction lending agency,for de"ficumarec of !Yi the work for which dos permit is all(Sec.3097,Cr,C.) G0 Lender's Name =z LeMCYS Address U Q 1 certify Oat 1 hast read'his application and sue that the aWn inforol is LL F correct.1 agree to comply with all city and county ordinances and ser¢laws relating to 0U building construction,and hereby auWorix mprexnutivea of this city to enter upon Oe W shove-mentioned Pmperty for inspection purposes. gy (Wt,)agree m save,indemnify and kap hamdess the City or Cupertino against rq liabilimejudgmens.costs and expenses which may in any way accmc agamstald City U z In corumuvee of the granting of this permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date (J SOURCE TIONS. / t� �''Uy 10-o Re-roofs Signature of Applicaro'Co m eon Orate HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will OeapPlin for futurebuilding occupectstom orharldlc Weetro usmaterial a defsmd by the Cupertino Municipal Codc.Chapter 9.12,and the Health and Safety Cala,QYcs 25532(x)? yNa All roofs shall be inspected prior to any roofing material being installed. 41 Will the. lican' /ffll! Wildin peen If a roof is installed without first obtainingan inspection,I agree to remove pp i pant tax muipmcu or nevus which P emit havallous air cmuminanu a defined by Oc Bay Arca Air Quality Management all new materials for inspection. Disuicp ( � C]Yes Y Nu 1 have mad the ha ccl materials mquimmena under Chapter 6.95 of the Calif.,. nu HcalO&SafctyCodo,Sttuau255(15.25533andM53C.Iwuk dOuifWc Wilding does not currently haw a count.that Is is my responsibility to runty the occupant of the mquim nnyh muvW met Prior to issuance of a CCWfeate of Signature of Applicant Date Owner m amhorizcd agent " � g Dau� �Do �� All roof coverings to be Class"B"or better ' CITY OF CUPERTINO trror PERMIT APPLICATION FORM CUPERTINO 060 00/ Adik N # � Date:I WP. Building Address: Mailing Address (if different from building address): az bo I Vv.S Owner's.Name: OT Cvpc(��-1 „-o Phone#: 77 3 y� 27Z Contractor: License#: Ac. ervicr— + De5fcvt lo ib-7 Contact: Phone:c64Z_ 131 L- Cupertino Business License#: R, ( ( k,-i m-,k Fax: Building Permit Info: �� BldgEl Elect d Plumb Id Mech Job Description: Residential El Re lice /`C Commercial �nCoommercial Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Goa Occupancy Group: �5 Type of Construction: Please check this box if the project is a second-story addition: ❑ lroject Size: Standard Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other A liances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BB0ILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax-Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 ZC10FCITY OF CUPERTINO ' PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL • Cesspool PLUMBING _ BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM13USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL WBREMRECEPT p Rem Non-Res Appliance ELECTRICAL E Pole/Platform Fixture ELECTRICAL ER Power Device/Apparatus ELECTRICAL Rc tl, Switch & Outlets ELECTRICAL CA Relocation of HoodMECHANICAL LT Repair/Alter Heating MECHANICAL PP Remodel Res A liance I ELECTRICAL 2of3 r (rC CITY OF CUPERTINO aTMOF PERMIT APPLICATION FORM CUPEkTINO uantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 7 BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR PlanningLon Range Residential PLANNING ZADDCHG Address Change BUILDING • 3 of 3