03070154 (2) L CITYOF CUPERTINO
a -
BUILDINGDIVISIONPERMIT CONTRAION
C^zTORINFURMA.T
3v+ r Ts�.¢fw4R trRast,.at&ate c-;Ws• 4.3
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO 03070154
0910 NORT92144 SQJ
OWNER'S NAME: 10570 S DEANZA BLVD PERMITISSUEDATB
AMM7R MTrHART, C)7 /j2 / no-:i
ONE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that T am limbed truer provisions lir Chapter 9(commencing p
<� with Section laa)of Division 3 of the Busineesand Pmfcodhm ede.and my license la w.A C
D q< LRtuft aan0 REPLACE FURNACE FiIVALE®
z License Lic.a
IQ Date Contractor
ley a I understand my plans shall he used uspublicc records
OCT 0 12003
C Liccnud Professional
OWNER-BUILDER m Ce Contr ON
BUILDING
.. w
S 1 hereby.form that I am exempt from Ne ConvssmrY License Law for the B I �■ING
S
00 following reason.(Section 7031.S.Business and Profession Code:Any city or county ���a//��V// riI
e which requires a Permit to construct.eller.improve,demolish,lir repair any suuetum
prior In its issuance,ala.requires the applicant for such .it,.Glc a signed statemem
That he is licensed pursuant to the pmviaion of the Comrumri License Law(Chapter 9 Sq.Ft. Floor Area Valuation
p�$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exemPl therefrom and the basis for the alleged etemp,ian.Any vialmon of
Section 7031.5 by any applicant for permit subjects the applicant o a civil Penalty of APN.Number Occupancy Type
not more than five hundred dollen(S500).
❑I,ot owner of the propcny,re is employees with wgu ss Nei(sok cW,Business
will da Newark.and the he Con: intended or License
affered for tale(SeewERSnotapply 7W,Business 1 — ROUGH mthi��1 Fictions
and ,ory wh arta Coda:The Contractor's License law dohs not apply lf an owner of
property who M1uildt orimpmves thereon,and who docuuchwokhimaf.rthmugA Ms 303 - ROUGH M CHANICAL
own employees,provided that ouch improvements are not intended or offered for sale.If, 304 — ROUGH ELECTRICAL
however,the building or improvement is old within one year of completion.Ne owr¢r.
builder will ban the burden of proving that he did not build or improve for purpose of 505 - FINAL ELECTRICAL
sale.).
❑1,as owner of the probably,am e.clusivcly contracting with licensed conmn ctoto 5 0 7 — FINAL PLUMBING
construct the pmjcc,(Sec.7lka,Business and Rotations Code)The Contactor(Li. 508 — FINAL MECHANICAL
cense law does not apply to in owner of profeny who builds or improves thereon.and .
who contracts rot such projects with a conmetor(s)licensed pursuant it the Contacon's
License Law.
❑I.c...pt no.Sec. .B&P C for this won
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby M.under penalty of perjury oro of the following declarations:
I have and will maintain a Cenificate of Cement self-insure for Worker's Compete
cion,.provided for by Section 3700 of the labor Code,for the perfm(nnm or the
wor orwhiehthispermilisceued. '
I have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Cade,for the performance of she work for which this Permit is imuetl.
My orke's Cnm enaction 1 wrante artier and Polity nu er
Center. Policy No.:
CERTIFICATE OFE MPDON PROM RLERS'
COMPENSA ION INSURANCE
Mis action need or M completed Ilion permit is for one hundred dollars,n 100)
or less.)
1 certify that in the performance or the work for which this permit is issued.I shall not
employ any person in any mannerso as to become subject a the Workeri Compcnsallon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become.ubj.t t.be Work,,a Compensation provisions of the Lahm Code,you most
.J O forthwith comply with such provisions or this Permit shall M deemed revoked.
z"" CONSTRUCTION LENDING AGENCY
'(r 4 I hereby affirm that there is a conswctinn lending agency fur the Performance lir
C$> the work fur which this permit is issued(Sec.3097,Civ.C.)
Is]Q lender's Name
Lender's Addnma
az
U O I terrify Inas 1 have read this application and sum that the above information is
I7. F cancer.I agree in comply wit all city and county ordinances nd sale laws relating m
OrU building cormuction,and hereby authotim rcpr.enutives of this city to enter upon the
W abovomeminned propeny f ape lion purposes.
gy (We)a rte to ave ode nify and keep harmless Ne City of Cupertino.,.lost
h liabilitics.ju enter cos antl s .which may in ray way¢cmc.gainst said City
U,Z in cnnaequc of the gr ling ftt permit.
" APmoeq. UNDE AN S D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC G LA
6vz
Re-roofs
Si,mu.m.f an an cmr te
HA RDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or Boom building occupant stare or handle harardWs material
.defined by the Cupertino Mo iM1 Code.Chapter 9.17,and the Health and Safety
ctde,semen zss37(.)?
ldbea ❑Yea All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wi mgarupant use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as def cd by the Bay Area Air Quality Management - all new materials 107 m$peCllOn.
ria,?
❑Yes ❑
I have the bar nusmaler'a yuircments truer Charter 6.95 of the Califno-
�lb
11.1to&S ty GMC, tions 755115.7. Sand 75534.i understand that irthe building
et, ly ve o apt,that it is my mibility to ono ly the rccu apt of Ne
n. k m etpdorbiastanteef.CentrX a tpytt. Signature of Applicant Date
own.roam .zed ageO.te All roof coverings to be Class"B" or better ,
0
' V CITY OF CUPERTINO
V iPERMIT APPLICATION FORM
APN# , , I / ► o as-s-
2
'lJ s-s-
Buildi dress: `h
11
Owne 'se: ��� ��� Phone#: _
Contra r: License - S
Contact• Cupertino Business License #:
Building Permit Info:
Bldg ) Elect ❑ Plumb ❑ Mech ❑
Job Desc iption: f n -ol „ern
Residential � Commercial ❑
For Residential Installations:
Attic ❑ 1' floor ❑ 2"d floor ❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Strue cu ,s-ie 'red for new installation ❑
N installation Plarmilig Ahproval Required
ost " is t - T f on�tion: Occupa cy r u :
Strapped l 0 atform Bonded Sq.Ft. Floor a:
New Location ❑ Replacement
Qty. if
Appfica eA 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