03030084 (2) •CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT * 60R
BUILDING ADDRESS: A PERFECT, CLIMATE ,' rEaMIr NO.
1
'S NAME:
10570 'S DEANZA BLVDdIT lssD A '
BLASKOVICH FRy 021J712002
PHL,4: (408) 861-9545 - SANITARY N0. CONTROLNO.
ARCHITECDENOINEER: .- _ BUILDING PERMIT INFO
BLDG ELECT PLUME' MECH
C= O [�
u0o LICENSED CONTRACTOR'S DECLARATION
1 Wmby aflbm that I are licensed under provision of Chapter 9(commencing Job DeSCrIpI1O
wiNSccalm1700D) Division 3 oflhe Buti end o(eadona Coda and my Evenseis
m cors Tome e eREPLACE FURNACE
�faa LlmnmGl � OR 1 0 2003
0 Dem RCHI Comn r _
LAcr N
Inn Y W umru Public mrnNs - BUILDING'gc7 Licensed Profess' al BUILDING
g OWNER-BUILDER DECLARATION
40 f l I hereby.(loco(Soction 1 1. exempt from tW Gammas Ch License Law for the -
o iz folwhich
cores a permit t 7113 s5,Business and r ve.demolish.
Codc:Any can aroounty
ure ,
$ which rcqulma a permit m construct.alter,Improv,deermit t or repair ed structure
�^ thtnoitsissuance,Juanttoto to theApplicantfm such Cantr wee Tensele a Lacdeuument
gg�O that he is licenced Pursuant to the of Divot of the Comnness Licenselaons(Chapter 9 Sq.Ft.FloorArea $ylF}aglOn
g $
that
Section 7000) Oivislon3 of slowBusinesseuand Profusions Code)or Y -
Nat he ts attempt n.,.from and do bss4 fm the Jlcged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant 10•dull penalty of 3 AM NOdIg[ 0 0 Occupancy Type
not mom Nm Eve hundred dollars(5500).
. ❑1,ssownerofthepmpeny.mmyemplaycuwlthwaguuthelrulectmpentkdon, pp pppp77rr((����
will do thework.and Neswcture is nollmended oroRered fondc(See.7044,Businua — R'e�st7CCt1OnS
and profusion Code:The Conuactots Licence law data not apply m an owner of r
propenywha bu0dsmimpmves Neman.and who d«ss«h work hlmselfarihrough his 303 - ROUGH 'M CHAN CAL
Own employes,pmvidcd that such Improvements am not intended or oEaed for sale.If, 304 — ROUGH ELECTRICAL
however,are building or Improvement Is sold within am year ofcompledon.Ne owner-
Wilder will haw dcWMenofprovmgMal le,did not build orImprove(orpurpose of 505 - FINAL ELECTRICAL
sok')' 507 - FINAL PLUMBING'
❑1,a owner or Ne property.em"elusively contracting with licensed contractors to c
- construct the project(See.7044.BwinessandProfeumr
Professions Code:) - '� 508 FINAL FINAL
came law data not apply to an owner of progeny who Wilds or improws Neuron,and,
who contracts for such projects with a comraclor(s)licensed pursuant to dm Contractor's
License law.
exempt under Su. .B At P C fm this mann
r - Dau .
WORKER'S COMPENSATION DECLARATION
1 Ihemhy&Man under penalty of perjury am of the following declarations:
❑l haw and will meinuln a CenirimMof Cementto wibinmm fm Workers Commn- -
sadon.As provided fm by Section 3700 of the Labor Code.for the Performance of the I
work for which this permit is issued
❑1 hew and will maintain Workers Compensation Insurance,As enquired by Section
37011 of the laWrCode,for the performance of the work for which this permit is found. '
My Warkcla Cam enaction Ineua=arrlennd policy num ram: .
er. Buy -
ERIFICATEOFE% PIONFRO ORKERS'
COMPENS IONINSURANCE ,
(This scedon need notal completed if the Permit is far one hundred d.IWA($I010
- I aoify that In the perinrmanro of Ne work for which this Permit Is Issued,I[hall not
employ any person In any manner an As to become subject o the Wurken'Compensation -
LawsofCalifomla.Deu
Applicant '
NOTICE TO APPLICANT:If,After making this Cet irua ,of Exemption,you should - -
become subject to the Worker's Compensstion provisions of the Leben Godo,you mute -
z forthwith comply with such previsions or this Permit[hall W doomed revoked.
T CONSTRUCTION LENDING AGENCY -
- F' I wrohy aEbm that Neu 6aconwcthe lending agency for NC Performance of
f$7 the work for which this Permit Is issurd(Sec.3097.Civ.C.)
l[7 QLendce.Name
Mz landela Address -
U O 1 certify that 1 haw mad this application and cute Not the o Ww Information is
torten.I agree to comply with all city and county ordinances and state Ism meting to -
O� `i.^1 btildingconwcdon,and hereby authmim mPrennutiws of this city to enter upon the
F{17 Ahow-mentioned property far inspection purposes. �/ S
gy (We)ag e to caw ndemni(y ted keep harmless the City of Cupertino againt I
A H.1,1111W,jud cuts,eo da;lmxos whlchmaylnanymyacruc againstuld Oty -
t„) eonsof a of e g ming of this Permit
APPLICA UN E DSTD WILL COMPLY WITH LL NON-POINT Issued by: Date
SOURCER ATI Ir
Re-roofs
Sig NnofAcant/Comnctor ate
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
WIII Oma plkant Or future building=upon[atom orhandle heurdous materiel
armed by the Cupertino Municipal Code,Chapur 9.12.and the Health and Safely -
A.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu or forum a
i If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant building«cupent tee cyulPmcnl or devious which
emit lustrous air camam] nu dc0ncd by the Dry Area Air Quality Management all new materials for inspection. '
Dinner? .•
❑Yes a .. .
I mad thest��
materials requlrsmcnts muds,Chains,6.95 of the Caliro,.
M.Hulth SAfclicu 25305.25533and255N.1undcnundthatifdc Wilding
dun not c a l h .duct It Is my responlbuity to notify the aceupoet of Ne
rcquircmcn ichpoortoIssuanceofaCcrtlTar mpmer. Signature of Applicant Dale,
JIQ
Owner or auThad a ate All roof coverings'to be Class "B"or better.
CITY OF CUPERTINO
C hi` ir; PERMIT APPLICATION FORM 3d✓?OlJ ��
APN #
Buildi Ad ess. C�
Owner;s Name: Ph ne#:
Y1 CD
Co a or: License i s
Gg 4f
Contac : �Vr Cuperto/$ in ss'License #:
Building Permit Info:
Bldg ❑ Elect O(!/ Plumb ❑ ech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1s1 floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same wei Additional weight (structural calcs) ❑
Struc 1�aulations required for w installation ❑
installation Plannin A roval quired
Cost Prome � �� c of Construction: Oc ancy oup
_. �
-sapped Ori Platform LJ Bonded LJ Sq.Ft. Floor Area:
New Location ❑ Re tacemen�
Qty. if
Applic 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 d, 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