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04070138 (2) CITY OF CUPERTINO ('� "j'�. 7 "7" 77 771"(�FT1r14e, � , W,1r0",' BUILDING DIVISION PERMITQl�r`1 ^�I"i•" �Fa.J.Ag4F'" pU1LDING ADDRESS: _ A PERFECT CLIMATE PERMITN00407.0138 49c; MC CTEMLAN Rn OWNER'S NAME: PBRM1T 155UEDATE INGU C ONE: SANITARYNO. CONTROLNO. 408 861- ARCHITECT/ENGINEER: BUILDING PERMIT INFO TED LDG ELECT PLUMB MECH 0 0 0 0 LoiC] LICENSED CONTRACTOR'S DECLARATION Job De5CT1pUOn� uq 1 Wrcby affirm that I am licensed under provisions of Chapter 9(commencing r ZV.S. with Section7000)ofDlvislan 3 ofthe Business and Professions Code.and my licenecis EEEEE. inm.ClAAAnderc ,Zvj(SES' REPLACE FURNACE & ADD A/C �� ® n�Z License Class Lk.g 1 Dam Cumrm o r - 1 p W ARCHITECTS DECLARATION 7 2004 u„IS 7 1 understand my plans shall he used as public records JUL "• D a s� LiccnmI hereby oval soli t�iNG OWNER-BUILDER DECLARATION Ys0 sR`atltl�B gy 1 hereby affirm that 1 1. exempt from IW Contractors License Law I'm the S:19 which following n.permit(Sectito 9D L5.Business and prove,a imil h.or: ,at,ily a l.ho y .J$ which requires a permit m cnnswct,alcor,improve,demolish,m repair any mmmum iz�� prior to its issuance,also mquimumit he applicant far such perto rile a signed statement that he is licensed pursuant the provisions of the Common's Licance Law(Chapter 9 Sq.Ft.Floor Area Valuation (commencing with Section 7")of Division 3 of the Business antl Professions Code)or '� .. that he is exempt therefrom and the basis for the alleged emmpton.Any violation of 'Section 7031.5 by any applicant for a permit subject use applicant o a civil penalty of 3 5kTN3fU5 ber0 0 Occupancy Type Tn'o`,...then five hundred dollen(S500). F]9,m owner of the property,Or my employees with wages As their sole compensation, will do the work and thestructure is not intended oroQered for aale(Sm.7094,Business and Profusions Code:The Conummrs Liam Law doei'not apply to en owner of Required Inspections ' property who builds or improves thereon,and who das such work him self or through his awn employe.,provided that such impms unamas ere not intended..offered foraale.If. however,Ne building or imp revemcut is sold within one year of mon,twOma,Neowner. builder will have the burden of proving Nat W did not build or improve for purpose of .lees). ❑1.as owner of the properly,am exclusively contracting with licensed contractors to construct the project(Sec.70".Business and Professions Code:)The Cauracue s Li. cense Law does not apply to an owner of property who Wilds or improves thereon,and, who contracts for such pmjecu with a conlractor(s)licensed pursuant o the Contractors License Law. - ❑Ismexam net�Se/e. ` ,B&PCf rfloa on Owner �,y/L��! ft Date - --WOR ER'SCOMPENSATIONDECLARATION 1 hereby af0rm under penalty.(perjury one of the following dttlentionm 1 have and will maintain a Certificate ofConant to self-insure for Worker's Compere rm Action,as provided for by Section 3700 of the LSr Code,for the perfoance of the work for which this permit is issued. I Ave and will maintain Worker's Compensation Insurance,as re uimd by Sector, of the Labor Code.for the performance of the work for which Nis Permit is issued. My Workers Cnmp�e.ai nn lose nm camicr and Poliry nu ber ate: Cartier. �- Policy No.: ,, CERTIFlCATE IF EXEM ON FROM RK RS' COMPENSATION INSURANCE (This section need not W completed Hthe permit is foto.hundred dollen 96100) m less.) I certify that In the performance of on,work for which Nis permit is issued.I shall not employ any parson in any manner.as to Wcome subject e Ne Workers'Compensation Laws of California.Data Appllcant NOTICE TO APPLICANT:If,after making this Certificate of Eacmpti m,you should become subject in the Worker's Compensation previsions of the Labor Code,you must .JO forthwith comply with such provisions or this permit shall W deemed mvnkcd. „z„► CONSTRUCTION LENDING AGENCY r I hereby affirm that them is a construction lending agency for tW Performance of the work for which this permit Is issued(Sec.3097,CN,C.) W A Leader's Name Z Lender's Address V I ceNfy that 1 have rad Nis application and smte that We about information is W(~ coned I agree to comply with all city and county ordinances and state laws relating to OV building consnuctian,and Wray mthorlm representatives of this city to enter upon the W ahove-menti ned property for inspection purposes 92. (We)agree to sass,indemnify and keep harmless the City of Cupertino against ,, liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. r s..i APPLICANT ERSTANDS AND WILL COMP6Y WITH ALL NON-POINT Issued by: Date )b:�L 50 RCE TION —7 �� Re-roofs Slinmure 6f App man/Conurne., Date a of Roof HAZARDOUS MATERIALS DISCLOSURE Typ Will the applicant or future building occupant store or handle hmmdous material as dented by the Cupertino Men cup.)Coda,Chapter 9.12.and the Health and Safety IDtan,t? Jc,Section 25532(x)? tj All roofs shall be inspected prior to any roofing material being installed. ❑Yes No Will the Apple, r future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it haimous air contaminants As dc0ned by the Bay Area Air Quality Management all new materials for inspection. 4 ❑yes �No Ihave rcml the hvaNasmateriabrcquiremcntsunder Chapter 6.95 of the Califor- Health&SafetyCade.Sccuom 25505.25533 and 25534.1 tomarand that if the buildings t currently has.atenen4 Nat it is my rcapo.ihiliry m notify IM occupant M Ne s gntswhi mut. tax ar eemneamoroeeancy. Signature of Applicant Date Owner or aamorived agent �Gl�/� >-o> All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 aClOF Fax(408)777-3333 UPEkTINO Building Department JOB ADDRESS- 2 ('2 dlPGLIERMIT # Z � 1 OWNER'S NAME: �� /� PHONE # $=2 5 7— 5 GENERAL CONTRACT FAX # _ 5 I am not using any subcontractors: Ktl� Z 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 4OLandscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile � Z � Owner/Contractor Signature Date CITY OF CUPERTINO OF UPEkTINO PERMIT APPLICATION FORM APN # � �OC /�1G j Date: Building Address: Owner's Name: 1 Phone#: AIA L OK 7—(Q 7, Contractor:1�( Phone: License #:W -96_'_nf�- S ?23/f�g Contact: Phone: Cupertino Business Lice nse #: Building Permit Info: Bldg ❑ Elect LLQ Plumb ❑ Mech 2--- Job Description: * add Residential [� Commercial ❑ (� For Residential Installations: Attic ❑ 1" floor ❑ 2nd floor� Adhere to min set back requirement❑ or Commercial Installations: eplacement same weight ❑ Additional weight (structural talcs) ❑ Structural Calculations required for new installation ❑ f New installation Plannin A royal Re uired ❑ Cost of Project: q Type of Construction: vo— Occup a cy gr i Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. oor Area: New Location ❑ Replacement ❑ Qt . tf ApulicaklFeeID 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 c&n 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 x/71- �