05060192 (2) CITY OF CUPERTINO 17
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ^�
BU ILDING ADDRESS: A PERFECT CLIMATE PERMIT NG05060192
OW NER'S NAME: PERMIT ISSUE DATE
NATHAN
ONE: SANITARY NO. CONTROL NO.
(4Q8) 861 -91;45
In
CHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELO PLO MEOCH
_ LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing lob Descriptiontl
Oth Sccuon]IXIU)uf Division3of NC Husinas and Pmrcssinas Cnde,and myliccnse is jj �B I�®
nn Tame and� b 315 REPLACE FURNACE �i� 'J rlI(T',Brkb=
- e�Sp1a�,aux L'c.g
ICGantraebr
ARCHnELTS DECLARAT,
dye I undcraunJ my plana shall W used u public records AUG
r U 7 ?OQ5
g u Licensed Psufessimm'
`03 OWNER-BUILDER DECLARATION yam, 'R o nn fpp��mm..,
0 1 hereby maxo affirm that 11. exempt from dr Conoactars License Law for the dam& !t ry p �S IN
'0 following nista.(Secdon,I m Business and Po Comoro Calc:Any city w forme IB a`1mH19 tll•(_t!�Op IIIIIIII
K$� which requires a parent w ennsvuct alter,improve,demuli h,.,repair any structure
ya771
i prior to iu issuartt,also requires the applicant for such permit to File a signed satement
< that he is licensed pursuanothe provisions Ofthe Conimcmr''sLicense aw(Chapter 9 Sq. Ft. Floor Area Valuation
sTFtt
a (commencing with Section70XS of Division 3 of the Business and Professions Coca)or
.y $
that he is exempt therefrom and the basis for the alleged caempdon.Any violation of
Sudan 7031.5 by airy applicant for a permit dbjecas the applicant an a civil penalty of 3 W413tiatcro 0 Occupancy Type
not mom than five hundred della.($500).
❑L u owncrl f the propcny or my cmploym mof1c nga as ad.(Sn lc 0,14,B xi c.
will do Jwwork,Cade: stumpranots LicanJ,Law dofaoalc(Sec.]pea,cuss,
of
and Prtywho u cede:The Conoxc em,License Law does work apply ff an owner ar ..Required Inspections
own am who builds orimprovach improvements
and who does such work himadf arthrough his
Win employees,provided that such improvements are not intended mplefired for comet
howevcq thebuilding orimprovingthsold at did enc year ofimproedon,areanso of
WRder will have be burden of proving that he did rot build or improve for puryme of
sated.
0 h as owner of the prot am exclusively contracting with licensed contractors to
comtmet the project(Sec.]Dare,Business and Professions Code:)The Contractors Li
more,law dors not apply us an owner of property who builds or improves thereon,and
who contracts for such pmjccm with a comrnctor(s)licensed pursuant an the Convector's
License Law.
I am exempt under Sec. .B 6 P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arae of the fallowing declarations:
I have and will maintain a Coaifiam of Conunuo self-insam Tor Worker'.Compcn-
sauna,as provided for by Section 37W of Ne Labor Code,far the pedo....of the
work for which this format is added.
1 have and will maintain Workcla Compensation Insurance.at required by Section
W of the labor Code,for the performance of the work for which this permit is issued.
My worker's
sCompensation Insurance carrier and Policy�nyyfm h�er�a�a(,:�(���1
Cartier: "I(.Llvj"k�� Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the permit is for one hundred dollars SIM
or less.)
1 canary that in the perramunee of dw work for which this Permit is issued.I shall not
employ any person in any mmncrso as m Wcome subject to are WorkerCompensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making tau Cenifmaw of Exemption,you should
become abject w the WO*Cx'&Compcwtion previsions of the Labor Code,you aero
,JZ fgMwith comply with.aeh provisions or this Permit hall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
Ithereby.111.Nat them isaromv at.lending Kerry far the performance of
a
she work fur which this permit is issued(Sec.3097.Civ.C.)
W Q Lender's Name
Z fender's Add.
U Q 1 cenify that 1 have rod this application and sate that the shout information is '
Is, F correct 1 ogre to comply with all city and county ordinances and mate laws relating w
0U building eonswctian,and hereby.uth.n.reprcsenutives of this city w enter upon the
r W above mentioned property for inspection purposes.
(We)agree Io at indemnify Nd lamp hanl.Ire City of C.,raina againstf'N riliabilities,judgments,coag andeapcnsrs which may in any way act.Cgturs, to City
of are
U z APPLICANTeUNDERSTANDS Aranting of tND em ILL COMPL H ALL NON-POINT Issued by: Date Gam^
SOUR9��EGULATIONS. (J ,
�Z'!(nA0-t 1 ✓ Re-roofs
Sign.,..of Applic.1Ctmncwr Dow
HAZARDOUS MATERIALS DISSURE Type of Roof
Will theapplicant or fuwd Wilding occupant sso or handle hvardous mawnal
as defined by the Cupertino Municipal Cock,Chapter 9.13,and the Haslth and Sorely
coda.Secdon 2ssu(a)p All roofs shall be inspected prior to an roofing material bei.
❑YeaNt P P Y g g installed.
Will the applicant o mwre building Occupant ate equipment orJcHea which If a roof is installed without first obtaining an inspection,I agree to remove
iI ha.:mous air anammar defined by the Bay Awa Air Quality Management all new materials for inspection.
❑Yes a
iatnec' ,Ry'N
1 have read the haestrdnus ma¢rialsrtquire ullIChapter6.95ofNeCalifor-
nuHcalth&Sts(cty Code,Sectiom 25"15.15533 and 25534.1 ndcrsund add irarc Willing
does a.(eurenlly have a want Nat it is my responsihi dy o mail'y tW cecapam of dw
requir en s which moa W met pno w vont r.Ce ¢ate of Occupancy.
c Signature of Applicant Date
Owner or amhmivud agent Date All roof coverings to be Class "B"or better
r Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRS: n PERMIT#
[QA- VY-MO-e-, pSa -oJ
OWNER'S NAME: Cl 1 -1 PHONE # o q(D -a
GENERAL CONTRACTOR: Epi) -t FAX #
I am not using any subcontractors: J11-ky L- i Q
Signature V Date
Please check applicable subcontractors and complete the following ' ormation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
J
Owner/Contractor Signature Date
CITY OF CUPERTINO G 6 0
1 FURNACE/AC o�
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: ,
a fbq c Vy(oc U_
QNvner's Name: Phone #:
(0 a
tractor: License#: r
l a1 c� ;
Contac : u ertino Business License #:
Building Permit Info: `1
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ ls` floor ❑ 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
Strapped Ll On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BRENIRECEPT 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 01 BUILDING