05120016 (2) CITY OF CUPERTINO 7 �%r*~7 �' ,_ "" ' " "`
BUILDING DIVISION PERMIT C�NTRt1C'TOR INFORMATIQN ';'
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO.05120016
1026 PENNINGTON LN
OWNER'S NAME: PERMIT ISSUE DATE
RODY GOTTWALD 10570
NE:
SANITARY NO. CONTROL NO.
(408) . 861-9545
AR CHITECTIENGINEER: p�a�` BUILDING PERMIT INFO
ER�,( q ELECT PLUMB MECH
tr� dra'ts'
O o LICENSED CONTRACTOR'S DECLARATION
Z C lob Description
I Wren,affirm thus 1 em II¢nsed under provision of Chap=9(commencing VN,r't
<U wild Secion7fDO)of Division 3 of ds Busneem and Prollmons Codc.and my license is
infunforeeaMe y REPLACE FURNACE �C
]sinZ LICC cc s l.ic.#
F p Dale Contncmr Y
Fry
ARCHHM DELLA h N dr,
f w U I undersunJ my Plans shll We a , rtmrd
.a u public cs l
n
e Licensed Pmfcuional
10
5 OWNER-BUILDER mDECLARATION.
C I Itemby,(Seco on 1 1. eanmpt from dm C.Ousalm..Co I3crnx city
o for thx
p O (allowing mason. orredon]fa construes.
Business and Pre.dem li Calc:MY city s runMe
which jus Wa a pcmit no coes da, alcor,improve,h Permit u of e a sig any wumsen, 2 9 8
. Prior m jus issuance,also mquima tM appliant for such permit m fire a signed summenl
< thalhenlicenascdPumsanlmthpovksiansoftheConuactor'sliccnmlaw(Chapur9 Sq.F[.Floor Area Valuation
eF0 (c,mcncingwlth Scctim700Mo(Divnion3of the Businasandp f=iona Cake)or
i $ Nat We is exempt therefrom and IM bun for die alleged esempuan.Any violation of
Section 7031.5 by any applicant for a permit subjec s dre applicant be a civil penalty of r Occupancy Type
not mom Nan five hundred dollars(5300).
I,u owner of the property,Or my employees with wage u Neal sole compessadon,
will do the wak and the structure u not intended or offered for u4(Sm.Man.Bounen Required Inspections
and Profesu iaCodx
Curie:The Canutorss m es License Law donot apply an mane,or q p
progeny who builds orimproves thereon,and who daessuch work himaelforthrough his
awnempla) ,pro &ddossmhimpmvemenuartnotinmMeA oroffeemiforsale.IL
however.the building or himovemcnt is sold within oro Year of comple m,de owner.
builder will have lite bumms of proving dot Inc did not build or improve for purpose of
cele.).
❑1.u owner of the property.am aclusively counseling with licensed containers an
conuucl the project(Sec.7(u14.Business aM Profusion Code:)The Cmuactor's Li- _
cine law does not apply m an owner of prvpert win,Wilds or improves thereon.and
who conmcu for such projects with a eonuaemr(s)licensed punned an use Co oractnr'r
License Law.
❑IamaemptunmrSee ,BhPCfor Jdsreson
103�AQ
ner Dau:
WORKER'S COMPENSATION DECLARATION
I bemby affirm under penalty of pejury me of the following declarabom
1 have and will maimain aCerdfsate ofComumt to self-invert for Wouler's Compen.
on,u provided for by Section 3700 of the Labor Code,for use peRomance of the
rk for which Nis permit is issued.
1 have aM will column Wofter Compensation Insunn¢,u required by Section
of lite Mbar Cade.for the penf...ofdte work forwb)m this permit u issuedy Wm Cam ,don bsmmme carrier and Policy nu b tic: --1746
rtier. Policy No.:
E IFICATEOFEKEMMONFR0 WORKERS'
COMPENSATION INSURANCE
(Des rimneed our W completedVthe permit nforonc hund Wllan(5100)
or less.)
1 unify the,in the Performance of the work for which dur Permit is issued.I shall not
employs, E. um are wblut Wwkcn'Compeosation
hems of®r, Due��
NOTiCant CtQ-- —
NOTICE TO ct P Use Woo:If,,for malting Nu Cof of Exemption,you should
borne subject y the Warh mo Compewuan provision of tale labor Coke-you muss
.J O forthwith comply with such provision r Nn permit shall be d¢med mated.
'Z CONSTRUCTION LENDING AGENCY
[-+ Ithereby affrm dot thcrt is a cmutmctinn lending agency for lite performarxe of
IL the work fur which Nis permit Is Wood(Se.3097,Cih,C.)
0 1<mtrts Name
iD. z Lender's Address
U Q 1 certify that 1 have rad this application and note dot the above infomation is
f' concoL I agnu b Comply wmdm all city aM Conroy mlinarcu aM sun laws Rating to
�U Wilding construction.and herby auJmmire rtiumere Ives of this City con enter upon the
W shove-mentioned pmpcny for infection purposes
CL. (We) mve
(We)aga ,indemnify and keep harmless the City of Cupcninm egaint
,A liabilities,Judgmcnu,cuss and eapene which may in any way armme against said City
U z in mnsegmnce of lime granting of Nn PcrmiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 21 Z Y3 f--
SOURCE REGULATIONS.
Re-roofs ( 1
Signuurt of ApplicanuCoARDOr Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Cogtnl mfMuni Wilding Co eceupantslam orand O hauNmurdSatmaterial
saju de0md by lite Cupertino Municipal Code,CTapter 9.12,and the HcaIN and Safety
oJc,Scrum 35532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu m
If a roof is installed without first obtainingan inspection,I agree to remove
Will the
applicant ofs.re in'
occupant ticequipmentorkevicerwhich P g
7nia
mit haraNnus eir cmominanu 0nctl by the Bay Arta Air Quality Managcmcnt all new materials for inspection.
isuicR
❑Yes No
I have mad the huasd...materiae requimmcnu under Cbapcu 6.95 of Ne Califon.
Hcalth h SafetyCade,Soctio s 35505,35533 zM25534.I urvkn and dcadme building
oes mt crnndy have•tennt.that Il u my responsibility m ratify the oaupant of litequiremema which muss be met prior Or umvwx of a Cen ficate of Occupancy.
Signature of Applicant Date
owner ormtherirzdagent Dam All 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
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
/oa� p S /1., a6 l
OWNER'S NAME: (v PHONE #W-95-;[ - 9
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
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
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
amCITY OF CUPERTINO FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
�5 Z o 2—
Building
Building Address:
loa�o I�eY�nn rt Lvl .
Owner's Name: <J Phone #:
Contractor: License #:
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech I�
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic �151 floor ❑ 2"d floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
a �,9 8. sS� lace 1-�t rn
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Ap licable Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN 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 Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING