05010075 (2) CITY OF CUPERTWO PERMIT �CU1�1TR'AC aR INFORMA'TIOW',,
BUILDING DIVISION kyr
BUIL DING ADDRESS: A PERFECT CLIMATE PERMIT No05/010075
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY O. C NTROL NO.
ARCHITECTIENOINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
o 0 0
ofl p fLICENSED CONTRACTORSDECLARATION. Job
1kmby spirer, 1 em der introduced, 9(commencing
with Secden 70k))dDlAson 3 aide,Buumas�Proks am m ' w
^� mfullfwmmdars S FURNACE REPLACEMENT
jH2 License Us.0
D4
Dow coptta'mr - [[
ARshall used
TION FFR 2OOJ
�i 1 uMenunJ my places atoll be laud u public mends
3 pp gp
end Licensed hereby
B U I L�®N ph q
OWNER-BUILDER DECLARATION INa1 B�'@VIJYi
,3:0 I hemhy alDnn on 1 a1.exempt from tial ContractorsCade:
Any c Law far the IBI
Oo followingmoon.permit
703 1.5,comment,alter, end ve,demobssim.Cadc:Anycity tcounty
$ which mqulma n pmmit re sthealter,improve,descach l rt mash any aaumum
'ya QQ
puarmiu iauance.alau rcquima tie apPliunt for such pcnnit mfilessigmdrtsumcol
C that he is licensed gooses to the Provisions of to Contractors Liwmc Law(Chapter 9 Sq. Ft. Floor Area Valua12
t On
(come,min{with section 70D0)of Division 3 of Ne Bushensand Profcarions Code)Or
$
that hela e+e Tin therefrom socul the basis fm the alleged c+amption.My violation of
Section 7031.5 by any applicant for a permit subjects the appllesnt to a evil penury a 3 691ANCIftro 0 Occupancy Type
oat mom Nu five hundred dollars(5500).
❑I.u awmr ofthe property,or my employees with wags a throsele compensation,
willdo Newark,andthestnetumianatinwM doraQemdrwasla(Sec.7044,Bnsiwen
and Professions Cade:The Con ra m's License Law does not apply in an owner of Required Inspections
property who Wilds or baprovea themon,and who dao such work himalf or through his
own employees,provided that such lmprosemenu to not Intended whitened forale.if.
haweves,the building or Lmprovemcot iasold within am year o(completion,the Owner.
builder will have de burden of proving Na he did not build or improve for purpose of
oto.).
❑1,as owner of the Property,am exclusively coutnming with licensed eommuchers to
construct the pmjact(Sec.71164,Bushes and Professions Cade:)The Cmuacmra U.
cera law does not apply m an owma of property who Milds or improve Hewn.and,
who contracts for such projects with a canmctor(s)licensed increased to the Contractor's
License law.
❑Iamcxunptunder See ,B&PCfrethisncWm
Owner Dae
WORKERS COMPENSATION DECLARATION
11
hereby shim under penalty of perjury am of the following helarWons:
I haw and will munuin a Certificate of Consent to selr-insert far Warkee,Campcn-
action,a provided for by Section 3700 of the Labor Code,for the perfarmenee of Ne
work for which this permit is issued.
1 have end will maintain Warker's Cam pen ution Insurance,as required by Scciton .. . . ",
of the Labor Code.for the performance of tk word,forwhich this permit is Issued.
My Workers ,n pe etla nu ce comer and Policy number am:
timer. policy No.:,4/MI
CERTIFICATEOFEX PI70N FROM WORKERS'
COMPENS ON INSURANCE
(Thu scctbresd notbecwpletW if tial)omit is foramhundmdal l ans(SIM)
or IM)
I certify Not in the performance of the wad fw which this permit is issued.I shall not
employ any peon in any manner so as to became subject to the Workme Compensadan
laws of Califomla.Data
Applicant
NOTICE TO APPLICANT:IL after making this CeniOesm of Eacmption,you should
become subject to the Worker's Compcnatlon previsions of the IaMr Cade,you most
OZ forthwith comply with such provisions or this permit Nell W deemed mwked.
r O CONSTRUCTION LENDING AGENCY
I,+ Ihemhy al@m thm Nem its convection lending agency for the performance of
C> den work for which 164 permit is iamd(sue.3097,Civ.C.)
fLl Qlander',Name
O Z Lender's Addmu
V O I cedry that I Mae mad this application aM sou that the than.infomodan it
Is, Woc0.I qme to comply with all city and county ordinances and sum laws misting to
V building combution.end kmby someone mpmaenutiwa of this city to enter upon use
W stove-mends ted property for inspection purposes.
0. (We)agree Io ave,indemnify and keep ha enlese the City of Cupertino against
h liabilities,judipsollcwts odea whichmay Inany way sec=against aid City /
(„)2 m conse9macc Nc{wring o(thia rm4
A RPL CANT N RSjpNDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Date
9 ONS.
'f� - Re-roofs
Signature ofAppEaatlContncmr Data
HAZARDOUS MATERIA DISCLOSURE Type of Roof
Will the applicant or future building accave stem rehandle hmardoas mamrial
a defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Id
ode,section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant re forum building meupant esu equipment re devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hevadous air ccalam ants u defined by the Bay Ams Air Quality Management all new materials for inspection.
istrict?
❑Yes Na
I I've
Je he. nus ma ialsmquimmenuunderChapur6.95of1he Califor.
ice Hulth&S ty Code.Scniaas35 5,25533 uJ 2S5M.1 understand thmifthc Millin{
me not cu tly h a una4 that 4 my responsibility m notify the aceupmt of theyulrtments bleb tkmelpi�r u cd.C.Oificau racrmry. Signature of Applicant Date
owner or athodncd agent / vData All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
V
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEKTINO
Building Department
JOB ADDRESS: PFiTT #
OWNER'S NAME: PHONE # 95
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 731
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
(Z-J 12
Owner/Contractor Signature Date
'A CITY OF CUPERTINO
FURNACE/AC c> " 7s�
PERTINO PERMIT APPLICATION FORM
APN # Date:
3 � '� - olD l • � • o
Building Ad ess:
h
Owner'same: Phone#:
08 3 8537
Co acto : Phone: License#:
Z&I
Contac Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Descriptio
Residential Comrfierciil ❑
For Re idential Installations:
Attic M 1` floor ❑ 2"d floor❑
dhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Re uired
Cost of Project: Type of Constru Oc4Floo .
41l c2CD
Strapped ❑ On Platform B nded ❑ Sq
New Location Replacement
Qty. if
Applic q., Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
— - BREM[AIRHAN 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 License BUILDING