03100103 CPPV OF CUPERT[NO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
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B DURESS: A PERFECT CLIMATE PERMIT NO 03100103
ER'SNAME: 10570 S DEANZA BLVD PERMITISSUEDATE
E: SANITARY NO. CONTROL N0.
(408) 861-9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION O O O
m 1 hereby affirm mat I am Bacnacd under provisions of Chapter 9(commencing lob Description
:i" with Scion7der Division 3af NC 0usinc"and Pmfcssiuns Co and myliccnse is o
Tac. infuBforte ands( c
;q? Lia. c Lie.a �S REPLACE FURNACE
�Eu Do I. commcmr ADD. AIR CONDITIONING �!
�� 1 1 ARCHIi0tTECTS DECLA A ON
eai 1 understand my plans shall he used as public mcnrdaat
o Licensed Professional
3 OWNER—BUILDER m Ce Cont ON
I a Y 1 hereby affirm o7031.5.
1 am exempt from the Gonlmelata License Law for rte
p o following reason.(Saito]W L5,Business and improve,
de um C,or Any city or county
f$ which rots issu a permit m construe,alar,improve,demolish, fi repair any statement
hat hePoor itsiensedpalso mymma pre inion o for Contractor
toiCame,ave stammcm
sso (commencmnmdpu"tion7 h)ofDivision
ivinnsnortheBmaialandmnxlaw(CM1aphr9 Sq.Ft.Floor Area Valua[�9515
2 s- that he exempt
with 9a"ian]and the
tiros for the
al eged exempt on.Any vi Cmle)or
that be u exempt tMrtfrom and me basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3��I�d`�4gP�er 0 0 Oeeu ane Type
not more Nan five hundred dollars($5007. p y yp
❑ Lu owner ofthe pmpcny,ormyemployces with wages as their sole compensation,
will do the work and dtestrueum is not intended or offered far sale(Sec.7044,Business
and Professions Cadc:The Contrscmes License taw does not apply to in owner of Required Insppections
property who bunds or improves hemon,and who doessuch work himseuor through his f 301 - ROUGH PLUMBING
own employ=.provided BOB such improvemenu.re not ntended orolfered for sale.B. 303 - ROUGH MECHANICAL
however,Ne building or improvement is sold within mote year of completion,the owner,
builder will have Ne burden of proving that he did not build or improve for purpose of 304 - ROUGH ELECTRICAL
salt.).
❑I,as owner of he property,am exclusively contracting with licensed contractors to 505 — FINAL ELECTRICAL
constmct the project(sec.7044,Business and Professions Cade:)The Contractor's Lb 507 — FINAL PLUMBING
scum Law does not apply to an owner of property who builds or improves daemon,and.
who contracts for such projects with a contracter(s)licanud pursuant o the Conoactofs 508 - FINAL MECHANICAL
License law.
I am exempt under See. ,B A,P C for this mavon
Data
WORKER'S COMPENSATION DECLARATION
T hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Ccnilmou of Convent to self-insure for Worker's Compen-
tion,as provided far by Section 37110 of the Labor Cote,for Ne performance of the
1
work
for which this permit is issued.
ryl nave and will maintain Worker's Compensation Insurance,as myuimd by Section
550(1 f Ne labor Calc.for the perfurmanec of the work for which this permit is issued.
My WorYYkq��er'ayf Codon sumncc carticr and Polity nu rt: /� t
Cemcr:r`vll`^ U'� Policy No.; rte //
CEKTLPICATEOP EMPIONFROMWORKERS'
COMPENSATION INSURANCE
MOSEccllrm..door becwnplcted if tle permit is for one hundred dollars IgRq)
nT less.)
1 mmfy that in the pafommnet,of the work for which this permit is issued.I Nall not
employ any person in any manner so as It become subject to the Worheri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis CcniGm c of Exemption,you should
become Subic"to the Worker's Compensation provisions of the Labor Coon.you must
�z foMwithcomplywithsuchProvisionsorthisfarmiIshallbedeemedrevoked.
ZO CONSTRUCTION LENDING AGENCY
1 hereby affirm that fere is a construction lending agency for the performance of
La> the work for which his permit is issued(Sec.3097,Civ.C.)
3.QLender's Name
Z, z Lender's Address
p 1 certify that 1 have read Nis application and stain that the above infoonniun is
y F building 1 anter to comply with all city and county nni ordinances and state laws relating h V
�O alm,,ongeonstmetion,and forebyauthome rmeas. natives of poll City to enter upon the
LT7 shove-marooned pmlerte for inape n puywTo
G
(We)egrte to save,indent'y Ynrm`ss the City of Cupertino against
to liibilidu,judgmenu.casts and pe swhich mey in an way acerae against said City
JZ in mmseyumec of Ne.gra`nti9 rf IS ornt. %
APPLICANT UNDERS'6 AND Wt L COMPLY GN-P INT Issued b
SOURCE'
I:GULATI I y Date
signuurc ofd Ijor"' tr-to' a-r
�I/ I1A2 DOUS MATERIALS DISCLOSURE a e of Roof
dlthe apps for future building occupant Store Of handle havaralms matetia
recd by the Cupeninn ni Uipet Code Chapter 9.12.and @c Heahh and safety
Section 2ss32(an All roofs shall be inspected prior to any roofing material being installed.
❑r
Will the applicant or fur m buil g occupant tau cyuipmcm or dcvi¢s which If.a roof is installed without first obtaining an inspection,I agree to remove
M1arardnus air conmmLoanu u mcg ea Nc Bay Area Air Quality Management all new materials for inspection.
uric(
❑yes
I have read the Commit auri quite entsunter Chapur6.95ofthe Califer
nix Health BSafcty Cadc; 25 .25533 an 25534.Iundcrsundthmifthchuilding
goes not a'unentlydLora am, t it is my res 'biliry to odty the u: pant of fc
reyuimmcn wFich mu bar of El peryBe up c
/(//I , Signature of Applicant Date
Owner or Mth Jagcn Data All roof coverings to be Class"B"or better
CITY OF CUPERTINO
FURNACE/AC
$ CUPERT INO PERMIT APPLICATION FORM
APN# 3S 90
- , _D q Date: I^
Building Address: / `f((/ (�
Owner's N!3e: . t NC Phone#: S
LA
Co tract ��� one: a(o l License#:�
Cogta . P e: � �U Cupertino/usin ss License#:
uca
Building Permit Info:
Bldg ❑ Elect*10 Plumb ❑ Mech
Job Description: K-r->p tt C9 _ y J ��
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1"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 Project: Type of�orys�ction: Oc pancy grou /
Strapped ❑ On Platform ❑ Bonded ❑ Sq.R. Floor Area:
New Location ❑ Replacement ❑
Qty. i
A c ble 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
PPERMTI'FEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING