04020031 CITY OF CUPERTINO �a £�s1d' � ` �F''
BUILDING DIVISION PERMIT s44��"";h �INF� "-" ,.�g Fel
BUILDING ADDRESS: A PERFECT CLIMATE PERMITN0.04020031
OWNER'S NAME: PERMIT ISSUE DATE
NE:
SANITARY G 4,12. OL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
B E PLUMB MECH
CIO
uoo LICENSED CONTRACTOR'S DECLARATION JobDescri tion
i m 1 bemby affum that I am licensed under provisions of Chapter 9(commencing - P p �a q
O with Section]ggs)ofDivisignSoftheBusinessan QSofysi,nsCade.andmyliwhe"is --- - ---_-- FEB 16 2004
' m in full If tI 5 -
� o Onin,
REPLACE FURNACE & ADD ASC
¢¢ A TECT ECLARA IO B LING
'�2 dm pie 1 he tl public c „_
If
OWNER-BUILDER DECLARATIO
<� 1 hereby affirm that I me exempt from Ne Continuum's License Law for the
p O following meson.(Section 7.031.5,Busi....nd Professions Cone:Any city or county
which requires a permit to cosine,aline improve.demolish,or repair my structure
Fid^ priors iuissuantt,at.roquimathcm,liant formula permit I.file.milendssaument
£ C that he is licensed pursuant to theprovislomfNeConuactm'sLicenseLaw(Chapter9 Sq.Ft.Floor Area Valuati
von
y $ (commencing with Section 7100)of Division 3 mile Business and Professions Colt)ur
that he is exempt therefrom and the hssis for the alleged conception.Any violation of ,{,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3
- 'gh.fl'IgOrO 0 Occupancy Type
not ream than five hundred dollars($500). J bi
. ❑L an owner ofthe property,or my employees with wages a their sole compensation,
will do the wark and Nesbuctum is not intended oroRemd rorsale(Sec.7W.Business
and Fro(eamru Cade:The Cammmors License Law does not apply m an owner of Required Inspections
property who builds or im proves thereon.and who does such weak him self or through his
own employers,provided thatmuch improvements are not intended woRered formk.if.
however,the building or improvement is sold within one yew of completion.the owner.
builder will have the burden of proving that u did not build or Improve for purpose of
sathJ.
❑1,as owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7064,Business and Professions Code:)The Contmetors U.
cons,law does not apply to an owner of property who builds or improves therms,and
who contracts for such projects with a contractor(s)licensed pursuant in the Contractor's
License Lew.
❑I am exempt under Sec. ,B$P C for this moon
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ore of aim following declamRons:
1 have and will
previdmaintain aCcnifiauaf Consento self-Insum for Worker's Compm.
miles.as ,d for by Scene.3700 of the labor Code.for the performance of the
work for which this permit is issued. --
I have and will maintain Workers ompensation Wurance,a inquired by Section
7 of the Labor Cede,fortheperf aneeaf the work for which this permit is laved.
My WahersC 1/I��j�ion m cameo of numbc�:
Carrier. Vi c 7 3 I5
CERTIFICA OF EMPf10N M WORKERS'
COMPENSATION INS NCE
(This auction need nolhecompleted If the permit is faros,hundmddullam($100)
less.)
I coolly that in the performance of the work for which this permit is issued,l shall not
employ any person in any mmncrso as to became object to the Workcrs'Compensmori
Laws of Calimrora.Dau
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become Subject in the Workers Compensation previsions of the labor Code,you must
,JO forNthmi
wicomply with such provisions or this pert shall be deemed revoked.
„z„► CONSTRUCTION LENDING AGENCY
[—i I hereby effort Nu them is it cowuucuon lending agency for Ne perfurmmce or
a> the work for which this permit is issued(See 3097,Civ.C.)
QLender's Name
Z)
z Lcnder's Address
U 0 I cenify that I have reed this application and suu that the above information is
II. Crai 1 ague to comply with all city and county rminances and suu laws mining to
0 building construction,and hereby amhories reprommadves or this city to cover upon Nc
0. above-mentioned property for marectiun purposaa
(We)agree to save,indemnify and keep harmless the City or Cupertino against
h Iiabili0es,judgments,costs and expenses which may in my way accmc against mid City
U,z in consequence of the granting of this permit.
APPLICANJ UNDERSTANDS ANA WILL COMPLY WITH ALL NON-POI Issued by: Date-2—er
5 ER GUUrIONS.
�- D� Re-roofs
Signaum of ApplicanvConuacur Dau
HAZARDOUS MATERIALS DISC SURE Type of Roof
Will the applicmt or future Wilding occupant atom or handle lumardous material
as defined by the Capsu loo Municipal Code,Chapter 9.12,and the Health and Safety
We,scetiezss3x(a)7
71 Yes
m NS' All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building acception use equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
It baaardous air contaminants u defncd by the Bay Afea Air Quality Management all new materials for inspection.
District?
❑Yes
Ihaveroadthemmoninuu,usmquim u under Chapter G95 of the Cato,
nia HcamrASafcsy Code,Scuumo25505.25533 J 5534.1undcrsundthmir Ncbuimin
Jas not curmn y have aym anL Net is my rca sihiliry m nnf ry aim wcup t of N
X mems ,h m2,kucu p t�aumc t f�=y. ore of Applicant Date
crmaohwizcdagenl All roof coverings to be Class"B”or better
CITY OF CUPERTINO
u. FURNACE/AC
• OF
CUPERTINO PERMIT APPLICATION FORM
Building Address:
7(oS2— W�
Owner's Name: �� Phone#:
Lem S �f5 sw -951-fS
Coma oc �\ \ Phone:t--cr e- '-1 -OS License #:
ontact. Ph ne: 6D x(o I ���e� Cu ertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
1 ciGt ✓�
Residential Commercial ❑
For R sidential Inaa llations:
Attic LJ I" floor LJ 2" floor ❑
Adhere to min set back requirement[I
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Typf Construction: Occupancy roup:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. oor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee 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
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 Lice se BUILDING
22_ .