05010144 (2) CITY OF CUPERTINO m' ?+ e 8; :»' ' a •�f'm, � �"
BUILDING DIVISION PERMIT �CQNTRACTQR�INFOIZMA TIO1V
BU ILDING ADDRESS: A PERFECT CLIMATE FERMITND05010144
OWNER'S NAME: PERMITL4UEDATE
NE: SANITARY NO. CONTROL NO.
408 861-954
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
11,00 LICENSED CONTRACTOR'S DECLARATION
0 1 Mmby affirm Ne,l am f he Bu under and
Proem of Code. 9(commencing Job DeS(ICI�I(151 e 1�
wish Sec lummy18)of Division that 13ofthc Business andvisionsiof Code.and my 9(com Cenci is Dep
1tl1�MV^ /J,uaq
.�„ tnrenforc Andeffe�y� 7w`� $$ REPLACE FURNACE
e'�x Da¢Lkm�C�[_Q(lp. CylodoLARA ION ft
c 2 1 understand my plana shall he used a public record, Fr'r ys R LL 2005
44y ddd
Licensed Profeuinnal
57
OWNER-BUILDER DECLARATION e Q@ &U y s
2 f 1 mason.
.(firm on I oro exempt from Ne Cnnlnemrl e:Any c Lew for the ��Sna' Uyy w`yy,Vq$ rs
p o following moron.arch u](131.5, t,Business and vet de of Code:Any city Or roomy
which its isu,permit re construct,al¢O impmn,demolish,At e.sig any mmclum
nnn
-ma prior to iuiensedprsusumcc.aim requires to he thovisioso for such ComnicmiOLicese signedstatement
a"� (Commthat lacing wit pursuant talkie provisions of the Contactorsnd Profession
(ChapterCOCA)or Sq.Ft. Floor Area Valuation
`d (end WA11ngwithemion70ndth Division tof he alleged
exe andon.Any
CMc)ur
��$ that he ie exempt,hcsefrom and 8e bats for the,Ilged twmptimn.Any violation of
Seaton 7031.5 by any applicant for a permit subjects the applicant o a civil penally of 3 61T0at&&er0 0 Occupancy Type
not more Nen rim hundred dollars(9500).
1,as evo W of she property,or my employee wish w,go as Weir sero Compensation,
will do the work,and the swclum is no,intended or offered Want.(St .7044.Business Required Inspections
and Professions Code:The Contractor's Liecse nse Law docs not apply,o an owner of q P
property who builds orimprovu thereon,end who does such work himselfmr through his
own employes,provided that such improvements sre not intended or offered(orale.IL
however,the building or improvement tswid within one yev e(eompletion,theowner-
builder will ham the burden of proving that he did no,build or Improve for purpose of
ale.).
❑I,as owner of We property,am exclusively contracting with licensed contractors to
consume,the project(Sec.7044,Business and Professions Code:)Tht Comramr's U.
cess law does no,apply W an owner of property who builds or improves Semon,and
who concocts for such projects with a comramr(s)licensed pursuant to the Conuanor's
License law.
❑1 am etmpt under Sec. .B 8 P C for this meson
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain ACenifieate of Consent to ulf-sum fm Worker's Compen-
asion,AS provided for by Section 7700 of the Labar Code,for the performance of the
work for which this permit is issued.
ban and will maintain Worker's Compensation Insurance,as required by Section
3 of the labor CoOe,for the performance of the work for which this permit is i11'
My Worker's a pese8o Ins- nm Cartier end Policy num cram: ?
Cartier' Policy No.: 14110
CERTIFICATE OFEEMPTION FROM WORKERS
COMPEN JW
INSURANCE
(ON Section need notbecmnplemd if IW Permit is Foram hundred dollars($100)
or leu.)
1 unify that In the perfnnnenue of she work for which the permit is issued.I Shall nm
employ any Person in any manner an AS W become Subject ld cite Worsen Compcnu,Ion .
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenlncse Of ESemPtion,you Mould
become Nhject 0 the Workers Compensation previsions of the labor Code,you must
70 forthwith comply with Such provisions nr this peank Shall M dccmcd mmkcd.
�Y CONSTRUCTION LENDING AGENCY
1 hCAmY affirm Wu Wert is a co mon flon lending agency for the performance of
Y.? the work for which this permit is issued(Sec.7041,Ci,C.)
Y0 Lmdera Name
7 z fanciers Addmu /
J t- 1 agree o c 1 Mm mad this city
aid coup and tum Wu tie above haflaws
istion o
F correct I agree to comply with y city and cosy oNinancer and city
law misting m
�U ahomngconwuctiroend hemby,uNon prposeunlatiruofthis ciq,o enter upon the
�G ,Iwvamemioned property for inspection pugmxa.
(We)agree to am,indemnify an p hrles tk City of Cupcnino against �...
T/1 Ilablli0n,judgments, eau $crpens a ich may In any way acme ag,inotand City . C-0
in conwquencc ofth gra in of this r U
APPLICANT UN R ANDS AND W COMPLY WITH ALL NON-POINT Issued by: Date
SQ11RCER GUL 1 �- '
Re-roofs
Signature of Ap,lisnVCan Corr Dam
HAZARDOUS MATERIALS DIS OSURE Type of Roof
Will the applicant or future building Occupant score or handle hu4Nous material
u defined by the Cupenino Municipal Code,Chapter 9,12,and the Health and Safety
Code.Seem.OyG 25552(')7 0 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ror Totem building Occupant caw equipment or devices;which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants As defined by the Bay Area Air Quality Management - all new materials for inspection.
atrict7
❑Yes )on
Ihave reed Naha 1! A,riaI "ems" der Chapter 6.95 of the Celifor,
ala Heald&SefctyC 6ons25W5, 5533=73554.1 undcmand thsHfthc building
docs not cuncntly be ren ret that I,'ggq y resposihiliry W nndfy the mcupent of the
7ryulmmcnu which be et prior W1'as cc oh CcWOcem of QCaPau. Signature of Applicant Date
owner,Or,mho cd as=ret / / Data 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
'UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE # 425'7 -,50-3 7
GENERAL CONTRAeTOR.-1 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 /57
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 Sj ature Date
CITY OF CUPERTINO
OFFURNACE/AC � S�
UPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address
-
/0 fie_
Own 's Name: Phone#:
er s 4oe =P59 .3F3 7
acto : Phone: icense#:
c �'!ol 95 �23r5
Contac . Phone: Cupertino Business License #:
BuildiUkennit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Descrip '
Residential Corfimereial ❑
For Residential Installations:
Attic ❑ 151 floor ❑ 2❑d floor❑
dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑• --Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Required ❑
-Cost of Project:' ' Type of Construction:!— - Occupancy group:
4
Strapped ❑ Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ R lacement�
Qty. if
Applicable 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 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL ,
_BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING