05080071 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �,,�ONTR'ATUR�IIYF,O' RMATION ,
BUILDING ADDRESS: AIR QUALITY HEATING & AIRC A5RND05080071
925 PROVIDENCE
OWNER'S NAME: PERMIT ISSUE DATE
FLORENCE LEE 714 NORTHRUP ST 2005
NE: SAN NO. CONTROL NO.
(408) 293-7138
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
l� I� l� o
'jop LICENSED CONTRAC TOWS DECLARATION Job Desire ff)F
r(� 1 hnmby M.Net I me licensed under provision of chapter 9(commmadng U Pp ,{� p
with Section 7WB of Division 3 ofmc Buslneu and Profession Code.and my license Is fl�' Fr. 17 k7 rd
inmBraceadd5 ADD A/C CONFORMING TO SETBACK�'REQ;.�®
Z License Cl Lk. (y
Desi Gantlaelar �� 'gym
ARCHITECTS OECLA f(J�
I understand my plan shall m used u public extends n oa
uLL Licensed Professional �� a/
O OWNER-BUILDER DECLARATION
E I hereby&(Gyro that 1 em exempt from me Contractors License w for the 1 aa
00 following mason.(Section 7031.5"Business and Profession Cade:Any city or county a'
$V. which requires a permit to construct.allay.Impmw,dcmolM.m repair easy muclure 4 3 0 0
-Z„ prior a its issumee.elsa requires thou Wil.,far such permit to fileaeignedruumcnl
i Nu heulinnsedFirmest WheprovisionsoftheConuacm'sl ..Law(Chapter9 Sq.Ft. Floor Area Valuation
S (commencing with Section 7000)of Division 3 of de Business and Profession Code)or
then he b exempt therefrom and the buts for than alleged esempdm.My viou0on of
Section 7031.5 by any applicant for a permit subjects the Applicant in a civil penalty of Occupancy Type
.at roue than five hundred dollars ISM
❑I,mownrof the property,ormyemployces with waguasthebmleeainpenation,
will do thework.md desuu=lure beat intended .Rend mrsom(Sec.70x,Business
anRequired Inspections
d Professions Com: e m e ns
Ties Commiserate,License Law domel apply owner of q P
property who bui Ida sur improons thereon,and who does such work Mmsel(ar through his
own employees.provided mel such improwmmu are,notmocr4ed iso@rya Russia.IL
howewr,the building or impoevement Is said within oar year of completion.Ne Owner.
builder will hew de burden of proving me,he did an,build or Improve for purpose of
exle.).
D 1,as owner of then property,am emlmively contracting with licensed conumtus to
construct Ne Project(Sec.7044.Business W Prones robe Cade:)The Conuacmrs U.
cane Law does not appy in m ownv of property aha lati1N or improves thereon.rod,
who canncu forauch projects with aconuactm(s)licensed Knows,to the Convanara
License Law.
❑I em exempt under See. ,B l P C for this moan
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby anion under Family of perjury one of The following decal Wow
I but.and
will maincom a ccriOnm of Cnneeal to self-Warm for WmkeraCampen-
salion,as provided for by Section 3700 of the Lwur Code.for the performmn of me
wart for which this permit is issued.
D 1 haw and will maintain Worker's Compensation Lawrence,as required by Section .
3700 of de labor Code,for the performance Of the work for which Nu permit It Issued.
My Wukne, Camp oda lowerann nmiu and Policy number sue:
Geier.--?}��PoINY FROM �e�D6
CERTI LATE OF EXEMPTION FROM 0RK•RS'
COMPENSATION INSURANCE
(This secdon need not be completed If the permit Is fo ane hundred dollen($100)
or lent.)
I today that in the performance of the work for which this permit is issued.I"I not
employ am'person In my mournorsa as to become subject to the Workus'Compensation
Laws of Califomla.DM
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you most
J O forthwith comply with such provision or this permit shall be deemed revoked.
z` CONSTRUCTION LENDING AGENCY
Ehereby am.am,ft.um
•conuctirm wading a genry far Nper(
e ..of
> Ne work for which this permit is issued(Sec.3097,Civ.C.)
WM Q Lender's NMC
7 Z Leaders Mdaes
V Q i cenify Na 1 low read LIT,application and stse Nan the&how information Is
Ly cmmct.1 agme m comply with all city and county ordimecaa and law laws relating to
l7 building convection.and hereby auNmire representatives of this city to mer upon tho
W ahow-mentioud property for Inspeedon purpo¢s
fi (We)Agra to save.indemnify and keep harmless the City of Cupertino against
vy liabilities,Judgments.emu and expenses which may in my way accrue against said Cly
V 7 in consequence of the Omling of this permit.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R 0 ATIONS.
�r((l�_ Re-roofs
Sngma OfA nCNUDm1 Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
wd y Cupentu(roue building Occupant Chamr 9A2,andtam c Health and
as defamed by tie Cupenime Municipal Code.Chaper 9.11,roti the HuIN roti Safcry
ode.Scctiaa z553z(a)7 `uuu All roofs shall be inspected prior to any roofing material being installed.
❑Yon A No
Will the applicant orlfuture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hmsamus air conuminmu u dc0eed by the Bay Amo Air Quality Management all new materials for inspection.
O rict7
Dyes �Nu
1 haw ad Lim waste.,awaumb requirements under lupwr6.95 arrive Collier.
nu Heal"SaRtyCode,Sections 25505.25533 and 25534.1 understood thulflhe building
dos not currently hew a wnml.that it is my ruponsibillly m na0'y Nc aceu rot of Ne
mqui n wren usbemelp' IoumaofaCcdilicateofOc IgnatureofApplicant Date
o rar,atha =d.II01 All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
si , Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4UPER,TINO
Building Department
JOB ADDRESS: PERMIT#
)u&l lrwD S'4 X 00 7
OWNER'S NAME: PHONE # —
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
er Contractor Signature Da e
CITY OF CUPERTINO
FURNACE/AC
t:1 C
CUPEkTINO PERMIT APPLICATION FORM
APN# -(_/
Building Add ss:
s ei)
Owner's Name: Phone #:
z,'6�6
Contra tor: License #: y�
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Job Description:
C M n.6TV 13 '
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1"floor 2"d floor❑
Adhere to min set back re uireme
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningA royal Re uired ❑
Cost of Project,: OD 00 Type of Construction: Occupancy group:
Strapped El On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 clin 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 Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License S J BUILDING