04090252 (2) CITY OF CUPERTINO
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ButLOIN DlVlsioN PERNIIT ,k, ,y„I, .,
OUILDI NG ADDRESS: A PERFECT CLIMATE PERMIT NO04O9OZ S2
PERMIT ISSUE DATE
OWNER'S NAME:
MIRAN SANITARY 0. ONTROL NO.,
He
BUIL°INO PERMR INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
Yp� - LICENSED CONTRACTOR'S DECLARATION Job Descrlpt MAUD
I hereby afRrm Nat 1 am beemsed under pmvieions of Chapter 9(commencing
O� with SecporyeOlM)ofDlWaion]of the Buvrvss and ofessin,u Cade.ana myliccnsc is
in ren f. and cir; NEW A/C UNIT (�(�T 1.
Date v Lic.M 111+1 2 �oO t
Oeste Cuntrmmr
RCNf1EC1-S D TION
I unticntand my plant shall W ucd u rccnNs
n
3 v. Lice d Pmfeuionel
5a OWNER-BUILDER A DECLARATION
BUILDING
iY I Wuhy affirm on I em.Baron,from Ne COnitens Co License Law for the
O O following ream..(Section 7(111.5.Businessland Rofessium Code:Any city or county
$lei which myuI.a permit m conswm,alter,improve,demolish,or repair any slncm,e
prior
m its issance,atm requires the applicant for such permit m file a signed statement Valuatton
HZ< Nat W is licensed pursunn in be provismm of the Connector'a U-nad Law(Chapter 9 Sq,Ft.Floor Area
$ (commencing with Section 7”)of Division 3 of the Busincm and Professions Cede)Of
that he la caempt therefrom and dm halt for IW aRegnd exemption.Any violation of
Section 7071.5 by any applicant for a Permit subjects the applicant,to a civil penally of 3 5WNQ'O Cro 0 Occupancy Type
not more Nan Eve hundred dollars(5500).
❑1,a Ownm of the pmpmy.err my employe.with wagra u dulr mle compemadon, .
will do tW work,and Neswnum is Out intended or offered bomala(Sec.70th.Busineu Required Inspections
and Prafessiom Code:The Contrmmr's Liceve Law does not apply to an owner Of
properly who builds mimproxea ti eslon.and whodoa suchwmghimmlf or Waugh his
own employee,provided Had such improvements are not intended oroffered f nraala IL
however.fee building or improvement is mid within one yen,of completion.the owner-
builder will have the burden of proving that he did not Wild or improve for purpose Of
ale.).
1,as Owner of one property,em exclusively contracting wit licensed contractors to
com r m the pmKm(Sec.7044,Bainess and R fessiom Cade)The Contractor's Lt.
came taw does not apply man Owner of property who Wilds err improves thereon,and,
who contracts for each projece,with aormracmr(s)licensed pursuant to the Conumtoes
License LJw.
I am exempt under Sec .B 6 P C for this recon
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby hat under penalty of perjury ane of tW following declus0om:
I have and will maintain aCcnlfinteof Co.mnuos it-lolme for W.ftesCompcn-
limic
on,u provided far by Section 3701 Of Of Labor Cade,fm the re fi rmmce of dte
for which Nis Permit is issued.
tenhave and will maintain Worker's Compenatlon Insurance,as required by Section
0 of Ne Labor Code,far Ne petformmce of Ne wmk for which Nis permit Ice issued.
Warkoes Comp nsatidebt nnacaqrrim�/gndPoI, mbar art:i -..... rt�.t[��/Po li. ..... I J_ .
CERTIFlCA OF FMPNI NFROM ORKERS'
COMPFNSA ON INSURANCE
(Thu section need but W completed If the Permit is for onchundruddollan($10)
mless.)
1 certify that in the Performance Of the work for which this penal,N issued.I shall not
employ any perm.in any manecr to u le Wcome abject to the Workers Comram.lim
Laws of California,Date
Applicant
NOTICE TO APPLICANT:If.after making this Ccrtifiate of Esemptian,you should
become subject m the Worker's Comported..pmvieions of the[tabor Cade,you must
QZ forthwith comply with such provisions or this Permit shall W deemed mvokcd.
C CONSTRUCTION LENDING AGENCY
EI hereby affirm Nat Nen is a construction lending agency for the perfmmance of
> the wish for which this Permit is issued(Sec.3097.Civ.C.)
ta7 Q Lender's None
=z Landers Address
U 0 1 certify Net 1 have rad this application and sate Nat Nc above intimidation is
Pcorrect.I agree to comply with all city and county ordinances and estate lawn mheing to
�O Wilding construction,e1.sundlumby euth and epmsematives of this clay reenter upon tW
W atom-menu mcd property,frr inspection purpatet
G
(We)agree to saw,indemnify end keep harmless the City of against
against
IA liabilitim,Judgments,tato and expenses which may in any way secret aSelnal aid City
V z in conaeyuenec Of Ne granting.(this permit
APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL N N-P INT Issued by: Date
'SOU E UyATIONS. LL /�
DU Re-roofs
Slrg cure o AP tandCantrutor DB1 " gyne of Roof
` ` HAZARDOUS MAT AIS DISCLO E
; Will NOapplicant or(umm Wilding occupentstom or handle buallous mearial
an def recd by the C.Penh Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will Nc applicant or future building aceupam um eyuipmal or devices witch If a roof is installed without first obtaining an inspection,I agree to remove
mil hamolous air cantamimnu ss dcOned by Ne Be,Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have mad Ne hmaNnusmeterialemquimmcnts under Chapter G95 of the Glifnr
.i.Hulth&Sarcty Code.Sccdom25505.25533ud25N.1undmsund NuifW Wilding
Jos not currently have a tenant.Net it a my responsibility m booty On mroupant of Ne
myuiremc laic fund,me,pnorwi c ofeCcniRcateofOccup Signature of Applicant Date
wner ac til o acd agent D,te Ali roof coverings to be Class"B"or better
' - Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
SUPEPTINO
Buildin De artment
JOB ADDRESS: �ZI 32 n Ot 7k, PERMIT# of p 2
OWNER'S NAME: o ( J �/ PHONE #,, JC?--
GENERAL CONTRACTOR: #
I am not using any subcontractors: ;
Signature Date
Please check applicable subcontractors and complete the followm information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical C Z3/�
Excavation
Fencing
Flooring: Carpeting
_
Linoleum/ Wood
__�9Glass / Glazing.
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ ontractor Signature 7 Date
M CITY OF CUPERTINO ^�
UPECITRTINO PERMIT APPLICATION FORM
APN # 052" Date: �y
Building Address: I a G
t
Owner's Name: 1 n/� Phone#:
U �J` b,�_�55
Contractor: Phon • .� License #:
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: `
G
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1 s` floor ❑ 2°d floor❑
Adhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy gr ;
f
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Are .
New Location ❑ Re lace t
Qty. if
A i'c4lf 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
P