05120012 (2) CCITY OF CUPERTINO
C,
BUILDING DIVISION PERMITATI
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B BUIEING ADDRESS: A PERFECT CLIMATE rtinanurNo.05120012
ull
0294 DEMPSTER AV
OWNER'S NAME: PERMIT ISSUE DATE
1
PERRY HANS 10570 S DEANZA FITUT) 12 /n2/2nns
SANITARY NO. CONTROL NO,
(408) . 861-9545 I
ARCH17ECTIENCINEER: BUILDING PERMIT INFO
BLDGI ff MECH PLUMB C=
0 zo LICENSED CONTRACTORS DECLARATION
I hereby all than I sm licensed under Provisions of Chapter 9(commencing Job Description
with Section 700M of Diiisim,3.1'the Business mad Pmf..ions Code.and my Ikutm e
in 1: LWL REPLACE FURNACE
;R2 Lt. - o
mor i-ol
ARCH171EX7'a Dem 1B— S DECLARATION
I understand my plans shall In used as public mccands
Licensed Professimull
OWNER. UILDERDECLARATION
g2 I homey in.the I am B.I.ps from&Comusamor's License Law for ft
He: following meson.(section 1031.5,Business and Proicasion,Code:Any city or county
jj� which reclulms a Permit to comment,altar,knimme,dcandsh,a repair any supuelum INS 3 5 7 5
1.4� pricarst its iseencesec.almiroquirestatapplicant fortich permitu,nk 4signodatmentem
40 test he isliccumod pursuant to the prunvisionsol'theCommeme's Licurso Law(Charser!) Sq.Ft. Floor Area 10
51 (commencing with Section 7000)of Division 3a[Lhe Bushemesand ProftecdoereCodc),or
Wt be 1, pl theme.and ft bad.for the alifteni exampli.Any lioladem Of
Secahm 1031.5 by ary,applicant For a per
subjects the applIment to a civil penalty of Grddupancy'l�pe
not more than flue hundred dollars(5500).
0 1,as Ounces of property,or my omplayms with wages a their stelcesurnpecendon,
will dc,the work.and the sunicluess hima intended or offered forando(Sec.7044,Business Required Inspect-ionvs
and Professions Code-The Contracem's Lima Law(ROn an does not apply Owner Of
properlywho build,tolerances demean,and whodoemseachwourichimselforthough his
onam employees,provided thalsech happeneencou;am nothatended oroffered restart.117.
however.the buildintor Mprowmeru is old withinorest year ofoompletime.ths,uwmm-
wilder,will haw one tounden of proving that he did son WW Or improve for purpose of
sate.).
0 1,a owner of the Property.am combatively commurting with seemed cenuaemta in
come=the project(Sec.7044,Business and Prolessom Code)The Contractors Ll.
comes Law does am apply W an owner of parqserty'wbct builds or improucel lbefteare.and,
who ourannea rour such pm)ma;with a cormseethe(s)lictersed reamm,in the Contractors
Lice.Lan
0 1 res esempt muse,Sm .B•P c for this meaccon,
Owner Gain
Adkk IWIOIIKP21 COMPENSATION DECLARATION
.Ince
I thaw and
r.under possity of perjury mat of the following iftedarsdamr.
se
ancruse a coadflm.fConsom be self-lasum("Wermescourmcm.
select.as provided for by Section 3700 Or the Latin,cuss,ror the pedoureareas Or ft
work for which this Permit is issued.
0 1 have and will maintain Worker's Compensation tnPuance,as required by Section
3700 often Letter Code,per the performance cribs work for which this Permit it bound.
M Worker C cut Insurance,earn"and Policy number=-
0 .14 on ma al --L�6
Carrier. Policy No.: _—SS_
My
�CSRMF]57TE OF MEMPTION FROM WO
COMPENSATION INSURANCE
(Thissectim,need not he completed!Ifft permit Is forme hundred dollars(3100)
or thns.)
I cerfify that in the ptriformants:of the work,for which this permit is immusel.I.hail not
entplityanyiecratatmanyman e w=a subject he the Warkma'Comperassidem
laws C11— ', 1 11
NOTICE TO'APP_UCANTtW
If,allm7making;this Comficam of Exemption,you should
hoomem subject in ties Woelcon's Compensation provisions of not Labor Coda.you miss
z forthwith comply with each provision or this Permit seat]be deemed invoked.
z C
CONSTRUCTION LENDING AGENCY
I hereby affiren that theme a construction landing.gency for the performance of
the work for which this permit is issued(Sec.3097.Civ.C,)
GE Lemicei Name
z Lenders Address
D
1 comfy that I haw read this application and sum the the above Information is
city met county indictment and state laws misting 0
0 building communction.and hereby sathOrm:MIXOMMA11M Ofthill City to emmuram ft
u-E come"1%g="comply with all
Lel atione-mcneloncel penitently for impection Purposes.
0. (We)agree pe on,indemnity and loops harrudw the My of Cupertino against
cn liabilities.judgments,costa and expenses which may In my my sceme,against said City
Z in consequence,of the panding of this PCMIL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. Re-roofs
Signmem ol'ApplicandCominuctor Dow /C
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fusion building occupant s "handle Incautious material
dented by One Cupertino Municipal Co ,deChapum,ter 9.12,and the Health and Safety
use.Section 2553211)7 All roofs shall be inspected prior to any roofing material being installed.
0y. 1Q4 If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building Occupant use,equipment Or devices which
It bacarrhou"air carmajoureame,a defined by ft Bay AM Air Quality an all new MB enals for inspection.
Dom"?
r]Yes
lhavc mad the cussedness muncrinds requinumna undcrChpwr6.95 of the Collins.
nia�k2ith&Safety C�.Sec�=25505,25533and23334. building
does net corectray,have a unam.the,it is my responsibility in notify the occapporm or ft
quircerems which entical be ML Prior be issuance or a Cerolicaut of Occupancy. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B"or better
Community Development
0 Torre Avenue
Cupertino A 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
,UPEkTINO
Building De artment
JOB ADDRESS: PERMIT
OWNER'S NAME: PHONE # -3
GENERAL CONTRACTOR. 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
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
ile
s ,
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC blyz 0-'aCO F
Z_
CUPEkTINO PERMIT APPLICATION FORM
APN # 3 z G � O z Date: Z Z aj
Building Address: I ' ��,, rr
aa�Cl Y sfe.Y
Owner's Name: Pho'ne
{-� ei#:
e_y1Y �fI S -ivSl" 30
Contractor: License #:
Per '-�Cc.-� �wt0. -e_ a 3 ISS
Contact: Cupertino B siness License #:
v,.
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Meeh C�
Job Description:
2 �mac.-e..w,eve a t-n 4 c
Residential Commercial ❑
For Res' ential Installations:
Attic VI" floor ❑ 2nd 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 Pr ect: Type of Construction: Occupancy cup:
3 57S 0 0
Strapped ❑ 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
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elee 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
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