04010045 (2) p CITY OF CUPERTINO
s BUILDING DIVISION PERMIT, CONTRACTOR INFORMATION
BU ILDING AGUE F; SUPREME AIR SYSTEMS PERMITNOD4010045
aOWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY N0. CONTROL NO.
lote-C.otericie,
CHITEC'VENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
3LICENSED CONTRACTOR'S DECLARATION IOU DOSCII IIOD N
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
h Section 7")of Division 3 of the Business and Professions Code.and my license is
ull foree and effect.
nen ansa Le.N REPLACE FURNACE (GAS)
JUN 9, 12004
J5 ARCHITECT-S DECLARATION
je 1 understand my plans shall M used as public recnNs 1'
;0y Licensed Pnsfcssinnel 13U1L0iNG
OWNER-BUILDER DECLARATION
.�<8 1 hereby affirm that I .exempt from the Commeto's License law but the
00 following mason.(Section 7031.5.Business and Professions Code:Any city or county
K m E which requires a Permit to construct,alter,improve,demolish,or repair any structure
nZ j- prior in its issuance,also requires the applicant for such permit to file a signed statement
g a that he is licensed pursuant Sq.Ft. Floor Area Valuation
ns
y$C0 (commencing with Section](l(10)of Division 3 of the Business and Professions Cottle)or
i 3 Nat he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ,.A.p],t.g�q�,,,,y,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penehy of 3J•f 13\Y'!g'tleT00 Occupancy Type
not mom than Eve hundred dollar,(11500). J1f N1'bI YY7
❑I,as owner of the property,or my employees with wages u heir sole compensation,
will do the work.and the awcture is not intended or offered for sale(Sec.]0a4,Business Required Inspections
end Professions Code:The Commnm's License Law does not apply m C an owner of q p
property who builds m improves hereon,and who does such work himself or through his
own employees,provided that such improvements are not intended oroRered for sale,If,
however,he building or improvement is sold within one year ofcomplOti n,he owner. -
builder will have the burden of proving hat he did not build or improve for purpose of
a .I.
1.as owner of the propeny,am exclusively convecting with licensed concretion to
construct he project(Sec.]004,Business and Professions Cade:)The Contractor's Li.
cense Law tloca not apply to an owner of property who builds or improve thereon,and
who comnctsfonueh proj tswith cmntrazror(s)licensed pontoons to the Contr¢toh
License Law
.
❑lamext tunde a .B&P C for thio..on
Own , Date
O CER'S ppl RATION
I hereby in.under.emlly ofperjuryo efollowing declarations:
I have and will maintain a Cenificam of Comenuo selDirem a for Worker's Compen.
aation,as provided for by Section 3]00 of he labor Code.for the performance Of the
work for which his permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3]00 of the Labor Code,for the p rformance of he work for which this permit is issued.
My is
Compensation Insurance carrier and Policy number am:
Cartier: - Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is formic hundred dollars(g1IX))
or Itis.)
1 certify that in the performance of the work for which his permit is issued,1 shall not
employ any person in any manner so as to become subject to he Workers'Compensation
Laws of California.Date
APPlicant _
NOTICE TO APPLICANT:IL aper making this Certificem of Exemption,you should
become subject be the Worker's Compeesadon provisions of the Ichor Code,you must
Oforthwith comply with such provisions or this Permit shall he deemed mvokcd. -
„za CONSTRUCTION LENDING AGENCY
[—r ti I hereby affirm that hem is a convection lending agency llive e performance of
C the work for which his permit is issued(Sec.3091.Civ.C.) "
W� Q Lendcts Name
a Z Lender's Address
U 0 1 certify hat 1 have read this application and sum that the above information is "
Yrcorrect.1 agree to comply with all city and county oNce
inans and stem laws minting to
01� building constriction,and hereby auhmrim representatives of his city to enter upon the
Uabove-mentioned propcny for inspersion purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against a.
rF. V] liabilities,judgments,costs and asperities which may in anyway seem againstsaid City
V iAnPPLICconsequence of the NDERST N u(IAhisND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULAT 1N .
Re-roofs
vers Appl61 icanUCmm.cmr Data -
HAZARDOUS MATERIALS DISCLOS Type Of ROOF
Will the applicant or future building Occupant store or handle heasrdous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
C
ode.SectionY.x zsppxan All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will he applicant or inure building occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
������//////❑Yes pLNO
1 have mal the ha cedmi maaterials requirements underChapmr6.95 ofhe Califor-
&SafcI Cotler oma 25505,25533 and 25530.1 understand hxtiftle building
s not c hove a¢ ant, t is my responsibility m no'ly he weepmt of he
i�'mmeets ice mull me "n rte iaamancm of a Certificate pang Signature of Applicant Date
t$wnm oracar;,—edOgent - Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
. - FURNACE/AC
UPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone#:
Q QC/2i2 D _<2 Z
Contractor hon : License#:
mac.
Contact: Ph ne: Cupertino Business icense #:
Building Permit Info: FGti nGtG�
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
For Residential I st Mations:
Attic ElIS` floor 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
eplacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑ _
New installation Plannin Approval Required ❑
Cost of P 'e It�n,� TDe of Construction: Occupancy gro
t/4-1
7/ v v /,7 r/rn fCe
Strappe ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area.
New Location ❑ ReplaceUint
Qty. if
Appligable 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
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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