03120048 (2) 7777777777777-777777
,CITY OF CUPERTINOT��a,�TTd '; ; ° , Q�
a BUILDING DIVISION PL`i1LLY111 y„ + ..M;
BGILDING ADDRESS: A PERFECT CLIMATE PERMIT"03120048
I PERMIT ISSUE DATE
OW NER'S NAME:
t1THLEEN K
SANITARY OL NO.
ONE:
(408) R151 -9545 BUILDING PERMIT INFO
ARCHITECT/ENGINEER: - BLDG ELECT PLUMB MECH
0 0 0 0
;30o LICENSED CONTRACTOR'S DECLARATION lob Description
[toi 1 hereby affirm that 1 Am licensed under provisions of Chapter 9(commencing
a� with Section 7IX)ti fDivialon3of the Businerst. Prousamas Code a yliccnM is C
dfaRfomeand f S EPLACE FURNACE KI D�A�/ ®
SSE LteenMCl o Lie.M
Y p Date ARCHITECTS DECLAR T
sL <W I undamand my phms shall M recd as public records JUN 0 2 2004
D1U
is u.to Licensed Professional
it OWNER-BUILDER DECLARATION
Mo
I hereby splintsNet I am exempt from the Contras es Lkcnx Law for the
O O following means.(Section 703 LS,Business and Professions Code:Any city of county
$ which requires a permit at enmtruct,eller.improve,demolish.or repair any structure
Pdor la
m its issuance,also requims the applicant far such permit to file a signed statement Valuat On
£ 58
thatheislicensed Forms,inmeprovisions ofMeConnector's License w(Chapter 9 Sq.Ft.Floor Area
y+ $ (commencing with Section 7000)of Division 3 of the Business and Professions Care)or
y ..
that he Is exempt therefrom and the but far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a perm)uubjects the applicant to a civil Penalty of 3 'ft*(;r0 0 Occupancy Type
not mom than five hundred dollars($500).
❑I,m owner of ante =an.
many employers with wages a els(See.
compensation,
will do thewons and the NucwMtnms Licences awdoe .1apply Im04a,Business Required Inspections
and en,who
Cade:The C s theme's License Lew lees Inst apply to an owner of q p
property who b.Indserri d that
such impr andwho doesouch work oroffe ed for ugh ale.
Own employees,provided Nmsuchimprovementartnot Intendedorferule. r- i
Wilds,.the building or'mpm proviag sold within one you of completion.Neo.of
builder will have tiro burden of proving Wer he did not build err improve for puryote of
sake.).
0 1,As owner of the pmp try,am exclusively contracting with licensed contractor to
compact the project(See.70ad,Business and Professions Cade:)The Contractoh U-
cense law does not apply to an owner of property who Wilda or improves thereon.and
who contract for such project widt a contracmr(s)licensed pursuant to Ne Contrmloes
Lkes.Law. - ..
0 1 am exempt under Sec. .B&P C for this ream^
Owner DAM
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Nulty of perjury ON of the fallowing declx xlimac
1 haw and will maintain a Ccnirimm of Consent b aclf-imum far WorkelsComPen-
sial u provided for by Section 3700 of the labor Code,for the perfor ounce of the
work for which this permit is issued
I have and will maintain Worker's Cnmpnn atim Insurance.As mquimd by Section
3 of Ne Labor Cade,far Nc performance of Ne work for which this permit is hatted.
My ricer'sCompemationlnwnncecarierand Polirynumber (19U -
Carrier. Policy No.:
TIP A E)I PTION FROM W RKERS'
COMPENS TIONINSURANCE
('Ibis Maim need not he completed if the permit is forone hundmddallars($I011)
or less.)
1 certify that in the performance of she work for which Nis permit is issued.l shall not
employ any Peron In any manner sin As M become subject to tite Workers'Compemmmn
Laws of California.Dato
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Workeri Compensation previsions of Ne labor Code,you must
z forthwith comply with such provisions or Nis Permit shall be decreed ranked. .
OCONSTRUCTION LENDING AGENCY
'ra I hereby affirm that there is a connmction lending agency for the performance of
kY, > the work for which this permit Is Issued(Scc.3097,Civ.C.)
W Q Lender's Name
Lcaderi Add.
U 0 I certify Nat I have mad this application and state that the above information is
V, 1" come,.I agree b comply with all clay and county ordinances and sum laws misting m
C)C) building construction,and hereby auahodm mpmsenutisv of Nis city to enter upon the
W shove-mentioned property for inspccad'Turposea. r
(We)agree to cave,indemnify and keep harmlm th ity o Cupertino against I/
y liabilities,judgments.cast and expcnus which may in an yacc egvnusud City
(„)z, in the of this permit.
r+ APPLICANT D TA SAND WIL WITH LL 7N -POINT Issued by: Date
SOURCE RE ONS.
LC
Re-roofs
Sign A 'Mxd` Dem
HAZARDOUS MATERIAL IS LOSURE Type of Roof
e applicant or future Wild'ng occupant store or hendlc hmardous material
As
de
by the Cupertino Mi let, Code,Chapter 9.12.end the It and Safely
Code,Section 25532M)7 All roofs shall be inspected prior to any roofing material being installed.
0 Yes u
Will Ne eFPlic or(til Wadding Occupant use equipment err devices wMeb If a roof is installed without first obtaining an inspection,I agree to remove
mit havardous air contaminant u dcri cd by the Bay Area Air Quality Management all new materials for inspection.
Dixrica?
0 Yen
I havemmf thehav ms rials myoimment under Chepter6.95 of the Califory
niaHeslth&Safcay Codes = 255 ead25534.1,adcrtnd thatifNc Wilding
docs not currarilly ham a t.that it is my responsibility to notify thc u:cupmt of the
'quimmcn hichm hem prion ' umceofaCcrtifmateaf cup cy. Signature of Applicant Date
owner are ived agent D, All roof coverings to be Class"B" or better
CITY OF CUPERTINO f
FURNACE/AC 6 3 C>'/l Z `��i�'
OF
CUPERTINO PERMIT APPLICATION FORM
APN # s / O
(> G O
Building Address:
Owner' ame Phon #:
08 (�-13 -aag '
Cory�caME /„ s Phone: License #:
Colnt�net, 1� Phone l +b�t Cupertino Business License #:
u
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description: e2op(ace AAcuQ mc—
Residential
p^c
Residential . Commercial ❑ l
For Rg idential In�a Nations:
Attic LJ 1" floor u 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ . Additional weight (structural calcs) El
Structural Calculations required for new installation 0
New installation Plann g Approval Required
Co, tlo Pro'e t: Type VIConstr ction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Locatio Re laceme
Qty. if
A igabje 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