05010096 (2) CI'T'Y OF CUPEWHIS10 '
BUILDING DIVISION PERMIT 4c-0 N' TRACT ORA NFORMATION.;�
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BUILDING ADDRESS: A PERFECT CLIMATE PERMIT N'05010096
22310 JANICE AV
OWNER'S NAME: PERMIT ISSUE DATE
SUSAN LIN 10570 S DEANZA BLVD Ol 18 2005
141 ONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECrrENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
ioo LICENSED CONTRACTOR'S DECLARATION'
( FF 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing lob Des"FIN
!qg�y�
(2W wilM1 Sccliun]pB(Buf Division Jorthc Ousincs and Pmfcssinns Cole end myliccns is � ;M1 ry
;�ved. mmu mbeana Bract. REPLACE FURNACE 0.�id•'J
? License Class CLyic➢ta (T�tnn[
i t-� Data ARCHnE6TS DECLA ION MAR 3p ZUtf�
E 1 medcrsund ary plan shell be used as puhht record
>yU
e Licensed Professional ram. 1f ff��,,
v0 5 OWNER-BUILDER DECLARATION ���p mak' ('� A
<P I hereby affirm That I am exempt from the Contractor's I,icens Law for the 1T(�`tt IkylS�ln/ �bmW}yf
O O following reason.(Seemed 7(1]1.5.Business and Pmfcssinns Code:Any city or county YY
which requires a permil to construct.alter.improve.demolish.or repair any so-undro 0 0 0
52f prior In its issuance.also requires the applicant for such Permit o file a signed statement
< that he is liccnsd pursuant in the provisions of the Contractors License,Law(Chapter 9 Sq.Ft. Floor Area Valuation
2FO (commencing with Section 70de of Division 3 of the Business and Professions Coaki or
N S Thal he is exempt mclefrom and the basis for the alleged exemption.Any violation of
Section 703 IS by any applicant for a permit subjects the applicant to a civil penally of
not more Nan five hundred dollars(S5f10). E Occupancy Type
1,u owner ofthe property,or my employees with wages az their sole compensation,
will do the work.and the swclum is not intended oroRead for sale(Sec.7614,Business
and Pntassions Code:Tho Contactors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself orNrough his
own employees,provided Nm such improvements are not intended or offered forsele.If.
however,the building or improvement is sold will one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for propos of
salt.).
❑ h as owrer of the proptny,am exclusively concocting wide licensed contractors to
consume(the project(Sec.71W4.Business and Professions Code)TM Contractor's Lt. _
cons,law docs not apply to an owner of property who Wilds or imp roses thcbor.and
who contacts for such projects wide a eontnctm(s)licensed pursuant W the Cantraeux'S
License Law.
O 1 am exempt under Sce. B h P C or mismatch
owner
wn Data
WORKER'S COMPENSATION DECLARATION
1 base,affirm under penalty of perjury be of the following declaration:
1 have and will maintain a Cenifeam of Cortsenuo self-insum her Worker's Comped.
cation,ss provided for by Section 37Mof dee"We Calc,for the performance of the
week
for which this permit is issued.
KYllhave and will maintain Worker's Compensation Insurance,u required by SO,don
of Nc labor Code.for the Pcrfurmmcc of the work for which this permit is issued.
My Workers rope atingle m net caricrand Policy numWr me
Carica '/ 1//L Policy N
CERTIFICATEOFEK PnONFROMWORKERS'
CONFESS TION INSURANCE
(ITE sctime decd not W completed if the permit is loran,hundred dollars(SIM)
or less.)
I certify Nat in Ne performance of de work for which this Permit is issued.I shall nm
employ any person in any manner in as to become subject to me Workers Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,aper making this Certificate of Exemption,you shoo Id ,
become subject to the Worker's Core creation provisions of the Labor Code,you must
�Z, forthwith comply with such provision or this Permit shall W deemedraveled.
zCONSTRUCTION LENDING AGENCY
1 tabby affirm that them is a construction lending agency lot dee performance of
X the work fur which this permit is issued(Sec.3097,Civ.C.)
'y Q lender's Name
7 Z Leadcr'e Addrns
0 I certify that 1 have read this application and sou that the above inrormatiun is
y F correct.I agree to comply with all city and county ordinances and state laws relating to
'U building codstuainn,and he miry so'horirc represenutivae of this city to titter drain the
= C shove-mentioned properly for inpcctio purposes.
(We)agac t save,indemnify keep formless the City of Cupertino against
tz) liabilitiu.judgmcn .costs and capcnss beech mayin anyway settee against said City
j Z i_cansequenet pr t ting or this perm . pQ)ryT Issued by: Date
A PPC cm U E S NDS AND W COMPLY WITH ALL NON-
SO��REO AT
Re-roofs
Signature of AppiicamlComrumr Data
HAZARDOUS MATERIALS D SCLOSURE Type of Roof
Will the applicant Lir f,roc building occupant store or handle harardous maenal
as defined by Ne Cormier,Municipal.Code.Chapter 9.12,and IW Health add Safety
code spy,2ss3z(an N All roofs shall be inspected prior to any roofing material being installed.
wu the appfit.mot building occupam use cyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
its hvardous air contaminants as defined by der Bay Area Air Quality Management all new materials for inspection.
islrin7
[3 yea �f1d
shave mail dee harallous
in Is myuismcnu under Chapter 695 of the Califon
nix HcaldehSafet CWe,Sections25.15,2553Jand255J4.lundersrandlealifthe Wilding
Jres nm areml have a c eel,that r 's my responihility m nodly lie mcursl of Ne
rtyuircmcnB whi bemuse h tett Ante air !uscc ofa Certificate of Occup
' , Signature of Applicant Dale
OwncrorauthorircJagcm Dab All roof coverings to be Class "B"or better
sid
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
/O /ee D •
OWNER'S NAME: �v+_ PHONE # ,,q -(0,x a
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
IIectrical
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
Til "
ZL I�� �- " / -/v ' GzS
Owner/Contractor Si 71ture Date
CITY OF CUPERTINO 6
rte., i :� = , r, I
CITY 01
UPERTINO PERMIT APPLICATION FORM
APN # 3s 3 / Date:
Building Address: r
Owner'sName: Phone #:
�..,i v�. � 0.25 • !o
cto p Phone: 5 License #:
Contact. Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
l e al
Residentialommercial E-]
For,Residential Installations:
Attic ❑ 1" floor ❑ 2"d floor ❑
Adhere to min setback requirement❑
'or Commercial Installations:
eplacement 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:
r�
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location E) Replacement
Qty. if
A le Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
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
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