03050097 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT M.NT'PA.TORINFOR�ON g
BUILDING ADDRESS: _ A PERFECT CLIMATE PEaMrr Ngo.0th Q3�050097
nr-7-7 PAR TLIRER MR
P8f2MR
OWNER'S NAME: 10570 S DEANZA BLVD U /'�1/Z003
'NE: (4 0 8) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BO EO PLO O
O6 LICENSED CONTRACTOR'S DECLARATION
U Job Description
I w 1 hereby affirm that 1 am licensed under pmvns leioof Chapter 9(commencing with Section 7011(0 of Divblon 3 ofthe Business and ProfculonsCode.and my limem is
inmemree ane R -� S INSTALL FURNACE IFRIMAL 593
j Z Ltccnsc CI Lk.N
a, DabARCHITEConeacmr
CPSDECLARA N
f namail upublicrecnNa JUN 0 9 2003
PIU
Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
2 0 2 1 hereby a(Sec Nal 1 1. exempt from O r CantramCode:Anse law for the
5 p O folwh coving teres a Permit t 71015,Buinces and he.dem li h.or eirny y or mousy
$ which requires a c.Alm re cores the alter,nt fmve,demolish,m e a sig any mrocture
prior mits iensedpAlm requites the provisions
forthe suchCon Pctor'bGlcse UW(ned mtemcm
-Z< (co me cingwiit Pureuam 70the ion 70DE)of Dillons of the a BusinessandProf UW Code)or Sq.Ft. Floor Area bY�l ajl0n
Eq E her
he
(commencing pt Sera ft.AndtfDtadsfr the
MeBusinessmated Profusions Code)ur YY
L mat io b ta1.5 b any applicant
li and me bub far be alleged eumant n.to Any l penalty
of
Section 7031.5 five
any applicant fora permit aubJuu Ne applicant to a civil penalty of 3&EIA NOWkr O O Occupancy Type
W,more Nen Ow huntlrttl dollen($500).
❑L u owner of the Property.or my employes with wages As their cele compeuadon,
will do Ne work,and the structure is not intended or offered for sale(Sec.7014,Business —
and ProfusioCade:The Committee, n ttees License Law donot apply b an Owner of 3 0 3 - ROUGH M CHAN CAL ns
ns
property who re
builds or improves thereon,and who docs such work himself or through his
awn employees,provided that such ireprowmenuw Out Intended araffand for ade.If, 304 — ROUGH ELECTRICAL
however,Ne Wilding Or improvement issold within one year of cemptedon,the award.
Wilder will have the Wrtlen of proving that he did not build or improve fm purpose of 505 - FINAL ELECTRICAL
sate')' 507 - FINAL PLUMBING
1,as owner of the Property,am eaclusively contracting with licensed conuacwn to
construct the project(Sec.7044,Business and Professions Code:)The Coneacme:U. 508 — FINAL MECHANICAL
cense Law does not apply In an owner of property who builds or improv demon,and,
who contracts for such projects with aconeactoKal licensed pursuant to me Commactoes
Lima.Law.
❑I am exempt under Sm. .B&P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty Of perjury aro of the fallowing chalantiou:
I have and will..IOWA a Certificate of Consent m selbinmre for Woddes Compete
adon,p provided for by Section 3700 of the labor Code,for de performance of me
work for which this permit is issued.
have and will mainuin Warkeea COmpewmon Insurance,u required by Sedan
3 of de Tabor Code.for de peKormanceof site woh forwhich rob permit is issued.
y Works s oro .don Insurance curie end Poiiry n W
Cartier. I Poiiry No, '
CERTIF�PDQN FROM WORKERS'
COMPENSATION INSURANCE
(Thlssectim need not Wcompleted Eft permit Is rmcmm hundmAdollan(SIM)
or less.)
1 tend,that in the performance of On work far which this permit Is Issued,1 shell not
employ any Person in any marX�aa t�hhame�pbjecHo the Wmmn Compens.quo
Laws of California.Oso
Applicant
NOTICE TO APPLICANT ,after making this Certificate of Exemption,you should .
become subject to me Workees Compensation previsions or me labor Case.you mum
.,O forthwith comply with such provisions ar this penniuhall be deemed rooked.
z► CONSTRUCTION LENDING AGENCY
't. 1 hereby affirm that mere is a emwrectinn tending agency for me Performance of
�i > the work for which his permit b issued(Sm.3097.Civ.C.)
121U 0
LendersName
7 Z
Lenders Address
I
U Q certifya that 1 have rod Mr.Application
and coup and suss that and
above iws reladun is
E•'
correct.1 agree c comply with all city and county ntatnantts and sum laws relating to
QU above-gconmruclion,and hereby mthoriampsemnutivu of this city to caw upon site
�a shove-mc e)all d I.
for inspection anwma
(We)agmem ave,indemnifyandhap harmless wCityof Cupcninoagainst
iFyN incoisequnce of egrassing of
esmitch may lnany wayeccme agalnnaid City
t.)z AcPLICAN consequence UNDERSTANDS
of this Permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaHDate
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will Ntapplicant or forum buildingOccupantCh amomar handle Health anmaterial
az defined by site Cupertino Muniri I Code.Chapter 9.13,mtl We Hulce and Safety
I
sis.oY.2ss32(,)7 a� All roofs shall be inspected prior to any roofing material being installed.
Will on applicant or future building occupam use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Immolo.s air cenumieV u fined by do Bay Area Air Quality Management all new materials for inspection.
smim7
❑Yes
I have mad me tole.��ttggttsumala requirements under Chapter 6.95 of the Califory
Honith&Safety ,Soc'dnt.5505,25533 and 25534.1 undcnlnnd that if me building
es not an Oil a ate mr(�Ihat it b my mspoembility to notify tM occupant of me mrcmcnis sett m pdo,toamanceor.Cerur¢at tt. ry. Signature GfApplicant Date
owner. rd ��01 All roof coverings to be Class"B" or better
CITY OF CUPERTINO o3
0 a
PERMIT APPLICATION FORM
APN # Date:
3S� o7o 3� S'Ja(/0-S
Build' Addres
r
Owner's e: Phone #:
F- D S
C tractor: - License#:
l 1 S
Co t CE: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: ins(tell rNa eD I ✓1 .e XS I-h r"1c LOCA-+2
Residential Commercial ❑
For Residential Installations:
Attic C1 I` floor ❑ 2"d floor �
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight,❑ Additional weight(structural calcs)
Structural Calculatro'ns required for new installation ❑
New installdtion Planning A�bAoval Required
Cost ofoject: _ Type of Construction: Occupancy group:
U
Strappe O�Rejp' lacement rm Bonded Sq.Ft. Floor Area:
New Loca ' ❑
Qty, f
App c b e 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
174 9
° 7. ��