04080167 (2) ' CITY OF CUPERTINO a Wa
BUILDING DIVISION PERMIT XONTRA T
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO.04080167
0795 ]PENINRULAR AV OWNER'S NAME: PERMIT LSSIfE DATE
ONE: SANITARY 0 TROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
ee BLDGO ELECT O PLUMB MECH
O O
J O Z LICENSED CONTRACT'OR'S DECLARATION IO ALE
1 hereby affirm that 1 am licensed under provisions of Chapter a(commencing
e0
withllforcnndeffecDivi'on 3oftheBusinusand Pro cssions Cede.andmylicensa is
5'g3 n'cnluraea"germ"' C) Ling 23(�✓`S REPLACE FURNACE
Dam comracmr 1I 04t?'t
,e ARCHITECT'S DECLA ATIOf AUG 0 2004
y I understand my plans shall h used a public rccertls
3 g Licensed hereby affix BUILDING
OWNER-BUILDER DECLARATION
+E 1 hereby affirm thin 11. "crept from the fesmons Co License Law for the
"o o which re reason.(Saltier 7 o s r B,aincss and Improve,
de Professions Calc:Any city s county
Ea
which requires a permit m construct,alter,hfor such
hPermitt care pair any structure
'n'f^ priemits lensed e,alro uyo the the of the Continuum's
License Law statement
��e Net me cing wit pursuant 7 the Provisions of fee a Business and
Lk¢nsa Law Professions DOPur 9 Sq.Ft.Floor Area Valuation
aF4 $ (cam tis exampt Scdion IDndth towns n3 of feeeged asaandon.AnviDOOR)or /
.- Net he ts eumpt therefrom and de baso for the alleged Gumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 A615 niblYer 0 0 Occupancy e
outm.R Nan five handrail dollar(5500). p Y�YP
I,as owner of the property,or my nmploycu with wages as their sole compensation,
will do Outwork,and she structure is unintended muffled!for sale(Sac.7044,Business
and Professions Cade:The Contsecmas License Law docs not apply in an owner of Required Inspections
property who builds or Improves theeon,and who doceauch work himself or through his
Own employee,provided that such impmvemenuare notintended oroRered foradle.if,
however,Ne building or improvement is said within one yea of completion,me Owner.
builder will have the burden of proving mat he did not Wild or improve for purpose of
.to I
❑1,as owner of the property,am"elusively contracting with licensed comocmrs to
construct the project(Sec.7044,Business and Profession;Code:)The Contncmr's Li-
came hew does not apply in an owner of progeny who holds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant in the Contractor' _
License Law.
❑I are exempt under Sec. ,B&PC for this accused
Owner Data
WORKER'S COMPENSATION DECLARATION t
I hereby nam,under penalty of perjury one of the following decimations: -
1 have and will maintain a Certificate of Consent o salf-insure for W"rkcr's Coalition.
sation,as provided for by Section 37M of the labor Code.for the performance of the
work for which this Permit is Raised.
ave and will minimum Worker's Compensation Insurance,a requited by Section
3700 of me labor Code,for me performance of the wok for which Nis Permit is issued.
My Workce Cnm matiyn Ins" nm carticr and Policy num Wr nm:
Carver. I / Policy No.:
�1� I9�.
CE TI F ON FROM WO KR ERS'
COMPENSATION INSURANCE
fThts section riled ambecompleted if the permit literate hundred dollars(SIN)
or)ass.)
1 certify that in the performance of the work for which this Permit is issued.I shall not
employ anyperson in any manner an a m become subject to thin Workcra Compensation
Laws of Cahfomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Lahr Code,you must
,J z forthwith comply wife such provisions or this permit shall W decreed revoked.
,'Z„O CONSTRUCTION LENDING AGENCY
'Cr I hereby affirm that there is a construction lending agency forme Performance of
Gni > tier work for which this permit is issued(Sec.3097,Civ.C.)
W� Q Lender's Name
Lender's Address
a z'
U Q I certify that I MVC Rad rola city
and corn and slam that and
oboes fulmination Is
IL H conch.1 ague m comply with all city and countyordinancesand amk lawn r upon
he
Q V aliewcngcnioned proentl hereby eumon p rposeentaliacs of eros city to enter upon gm
about-(Wtian re in save for iePccdon Purposes.
y
(We)agree m ave,indemnify and keep hay finnan the City of Cupertino s against
N in
of die counting expenseswhichmay in any way accrue against said City
C.>`,L A P41CAcnct of the TSTAgrunting of A permit.
lot APPLICA ND RSTANDS AND W LL COMPLY WITH ALL t4ON-P INT Issued by: Date
SOURC DNS. �j� (7(/ O�
/Vf�ctor i r -UX-IJ Re-roofs
Cignajarc of ApplicaHAZARDOU Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(Muni building e,Chapter
score or handle h eaMoua material
a defined by res Cupertino Municipal Code,ChaPmr 9.12,and res Health and Safety
,dowaJe.Scatiet,25532(a)7
Yet, All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or umrc Wilding occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haysrdous air centsmin u mcJ by the Ray Aua Air Quality Managcmcnt all new materials for inspection.
Disuict7
El Yes ] e
1haveminitheha N! ndamnalstcyuiumentsundcrchapter 6.95ofine Califim.
ria H" &
Ith Safely Codc,Sections 8505.25533 and 25534.1 understand mulithe building
Joea not by ha a snort.Nm itis my rens ility m notify me a:cupant of the
rayui h'h un metp'ort issuanc aC am ofOccuP Signature of Applicant Date
Owns eram enze agent —(Data - All roof coverings to be Class"B"or better
_ Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
�UPEI�TINO
BuildingDe artment.
JOB ADDRESS: PERMIT # 0 I /jo Q
d-7j �l t I
OWNER'S NAME: PHONE
GENERAL CONTRA OR VMj
// FAX # -�5[
I am not using any subcontractorsc-: 1/ /�9 \ /d D
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical 6c. C A S
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
411 X�
Owner/Contractor Signature Date
spa I
CITY OF CUPERTINO
f;VFNACE/AC 6)
UPEI,TINO PERMIT APPLICATION FORM
APN # 31 ' _Q3— O 2-1 Date: O
�P b
Building Address:
017g5 P v) iviE a:r Pve .
Owner's Name: , kv Phone #:q/„�30
Contractor: � - I t Phone: �� _ 5 S License #: 1 /L>
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect 9--1, Plumb ❑ Mech L9
Job Description:
Residential Bl Commercial ❑
For Residential Installations:
Attic ❑ Is`floor ❑ 2nd floor❑
Adhere to min setback requirement❑
or Commercial Installations:
eplacemein sante weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑ �.
New installation Planning Approval Required ❑ /
Cost of Project: Type of Construction: Occup an gr p:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floo
New Location ❑ Replacement ❑
Qty.
-App1 ale 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 Licens BUILDING