03090110 (2) CITY OF CUPERTINO "may u • ' `� " 2
a BUILDING DIVISION PERMIT ONTRA TOR INFORMATION -
5 BUILDINGADDRESS: A PERFECT CLIMATE PERMITN0.3090110
OWNER'S NAME: 10570 S DEANZA BLVD mRmrr ISSUE DATE
ONE: (408) 861-9545 SANITARY NO. CONTROL.NO.
ILI,...
CHITECTYENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT00.'S DECLARATION
IlI hereby affirm than I am fdicfid under nd Proom ofs Code, 9 my lmencing JOb DCSCTIpIl00
Senion ndelpte Dlvixion7of NC Buaincu end Profcuinns Codc.and myliccnu is
oll Claandelle"' REPLACE A/C UNIT
Class Lim.N '
w Dam Contractor
e ARCHITECT'S DECLARATION
e I understand my plans shell W used as public records
y6
y C Licensed Professional
5
OWNER-BUILDER DECLARATION
M I hereby affirm that I em exempt from the Contractor's Licenu Law for the
p o following mason.(Section 7071.5,Business and Proreuions Code:Any city or county
S$ which requires a permit to construct.alter.improve.demniteh,or repair any sumetum
_Zy prior in its issuance.&)an require the applicant for such Permit to file a signed statement
m<
that he is licensed Furman,to the provisions of the Contractor's Limnu Law(Chapter 9 Sq.Ft. Floor Area Valuation
2F� (Commencing with Section 7000)of Division 3 of the Business and Professions Coiled or
Nal he is exempt thcmfrom and the Buis for the alleged exemption.Any violation of 35611002 . 00
Section 7071.5 by any applicant for a permit subjects the applicant to a civil Penalty of ,APN Number -.. Occupancy Type
not more than five hundred dollen($5001. - - '" "" -'—-
1,u owner of the property,or my employees with wags as their sole compensation,
will do the work and be svumue is not intended or offered fonale(Sec.7044,Busims1 11 -
and Professions Code:The Contractor's License Law dam not apply to an owner of 3 0 3 - ROUGH M HAN ecutins
property whobuilds or improves thereon,and whodassuch work himself or through his AL
own employem,provided thatsuch improvements art not intended mattered formic.If, 304 - ROUGH ELECTRICAL
however,lie building or improvement is sold within one year of completion,the owner. -
builder will have the burden of proving that he did not build or improve for purymc of 505 - FINAL ELECTRICAL
tak'I' 507 - FINAL PLUMBING _
u owner of ct property,,Bexclusivelysinend convecting with licensed ronvacrors io
c 'wcl the project(See 7W,Business end professions Code:)'Ihe Con leactor3 a 508 - FINAL MECHANICAL
room,Lew docs not apply to an owner of pmperty who Wilds or improves thereon,and,
whocon tit form eh injects with a cord"Ictorta mud pursuance the Contractor's
License Lew
0
1 m ,B&P Nis aro
0 r
IXI!IMIPEt RATION I ..- ..
1 hereby aRrm under pemhy of perjury one (th ollowing dedanuons:
Thew end will mainuineCeniOc,mof Content to ul6insum for Workers Camp,m
lion,m provided for by Section 7700 of the Labor Code.for the performance of the -
work for which this permit is issued.
1 have and will maintain Worked Compensation Insurance,as mqumed by Section
7700 of the Lebo,Code,for the performance of the work for which this Permit is issued.
My Workers Compensation Insurance carter and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
madsacedon need not be completed ifft Permit Is(mono hundred dollar(SIM)
or kni
I minify that in the performance of the work rot which this Permit is issued.l mail not
employ any person in any manner an as to become subjecuo the Worked Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this CCrhnctte of Exemption,you should
become sohjcet to the Worker's Comps num on provisions of the labor Crete.you must
=Z forthwith comply with such provisions or this permit shall IDI deemed revoked.
OCONSTRUCTION LENDING AGENCY
I hereby affirm Nu Nett it,construction lending agency for the lerrurmamre or
x dm work for which this permit is issued(Sec.7097,Civ.C.)
37 Q Lender's Name
z Lender's Address
;)0 1 certify Nal I have rad Nis application and mute but the above information is -
y
come,.I agree to comply with all city and county ordinances and slate laws miming to
J Wilding construction.and hereby aithorne reprosermiws of this city to enter upon the
h ahmc-nom limed property for inspection Purpoua
y (We)agree to saw,indemnify and keep harmless tie City of Cupertino gains,
(n liabilities,judgmems,costs and expenses which may in any way accrue against sand City
J 7 A cones uenccof do,UNDESTforming of this permhLL COMPLY WITH AI,L N -POI Issued by: Date I/
F7 A C
_ Re-roofs
MIR a HAZA DOUS MATERIALS IS OSURE Da Type of Roof
Will the applicant or future building occupan or handle hamrdous material
m declined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
C
ode.section us72(a)7 All roofs shall be inspected prior to any roofing material being installed.
ri Yes
Will the applicant or f Modeling Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ha,ardoum air contaminants u unlined by Ibe Bay Area Air Quality Management all new materials for inspection.
ict7
❑Yes
I have mad the W]ardom materials requirements under Chapter 6,95 urine Caliror.
Safcry ,Srcmay 25505.25573 and 25574.1 toderswd Nuirthc iluing
m w a enan min1hy tonoul'y I -cu t 0f theI met to sac cofaCc iGteorSignature of Applicant Date
thotln agent D,m All roof coverings to be Class "B" or better
CITY OF CUPERTINO
FURNACE/AC o o I ( c)
CUPEkTINO PERMIT APPLICATION FORM
APN# S- { l / Date: )
Build' Add
Addre s:
1� a.� c�A ei- c
Owner's Name: ' ��V�#:�3- p ��/
Con actor: ^liI yam` ` 6(A" License #:
ak
Contact: d Cupertino Business License #:
Building Permit Info:
Bldg ❑ Ele Plumb ❑ Mec
Job Descriptio9,
I�.e, laces old, 4 le, w 44A- W-tAr, 4t-Oe.2 fj Lv t4-.
Residential J91- Commercial ❑
For Residential Installations:
Attic ❑ 1" floor W2nd floor ❑
Adhere to min set back re uirement® So eA-,e- Cs,,, �/�
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New ' stallation Plannin roval Required F-1 ZA
C f Pr / Type of Const ct' n: Occupancy group:
Str ped LJ On Platform LJ Bon ed Sq.Ft. Floor Area:
New Location ElReplacement El
Qty. .
Appl' e 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 License BUILDING
2.
i� / x°. 77