03110122 (2) CITY OF CUPERTINO AK,
v Md r:>hri
BUILDING DIVISION PERMIT CONTRACTOR INFORATION
BUILDINGADDRESS: A PERFECT CLIMATE PERMIT N'03110122
1 8625 RAT-YA 171
OWNER'S NAMM PERMIT ISSUE DATE
\RILYN WILLIAMS 10570 S DEANZA BLVD 11/20/2003
NE: SANITARY NO, CONTROL NO.
(408) 861-9545
ARCHITEC IENGINGER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
iOD LICENSED CONTRACTOR'S DECLARATION Job Description
t I thereby affirm that 1 em licensed under provisions of Chapter 9(commencing p
+�� with Scaion7 rvi' n 3ofthe Besinau and C ylic°rase is PLACE 2 WALL FURNACES
mfulifome and (yQ,
j License v Lic.X
Dale Cun rack
ARCHITECT-S DECLARATION
f U 1 understand my plans shell he used ss public ucords
G Licensed Professional
g OWNER-BUILDER DECLARATION
<� 1 hereby,(Sere than 1 em exempt froms an the Contmcmrs License Lew for the
follBOO whnwingiflus. (Section com 7031.5,Business and improve,
d.nm Ca rte:Any city orcounty
S$ whichiquires•permit reptimatea@cimprov,h Permits Or.,sita sigan,tuumure 2025
Z�^ that he its ceased e,alsurequires lhovisio cam for anchpermicsLNcse Lured statement
+�x< (cot he islicensedWith
punuonl to the of Division
of the Contractor'ssincend Professions
(Chapter Sq. Ft. Floor Area Valuation
'R E that M is
(commencing Sanson 70 sad the
D alis f r the
the B ed axe and on.Any
Craft)of
i?�$ Nel he u exempt therefrom end de bash far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penehy of
net moa Iran me hundred doll...esoo). a Occupancy Type
❑I,as owner of Ilio progeny,or my employe"with wages as mein sole compensation.
will do the work,and 0..Waart is not intended or offered(or sale(See.71344.Business
and Profesahm,Code:The Commoun's License Law does not apply to an owner of Required Inspections
property who build,or improves Nemo^,and whoddes such work himself orduough his
own employees,provided that such impowmrnts art not intended or ofread torula It. s.�
however.the huilding or improvement is sold within one year ofcomplcuou,loanwncr- P
builder will have the burden of moving than he did nm Wild or improve f pu1,a,own"of the progeny,em exclusively contracting with liccnacd cenuamna to
constructconsct the project(Sec.7044,Business eo.acTurand Professions Code:)ThCs LIcense Isw dra os not apply to an owner of progeny who Wilds orimproves tkaon,andwho contfor such projectswith a contractor(,)licensed pursuant to dtc Contnaof,LicenseLaw. � --t—
❑I am exempt under Sec. B&P C for Igii.aeuoM
Owner Data _
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of she following declarations:
I have and will maintain a CenlOcau of Consent to self-insure for Workers Compen.
$.,I a,u provided for by Section 37M of the Labor Cade,for the Performance of the
for which this permit is issued.
I have and will maintain Workers Compensation Insurance,ss required by Section
3 W of the La Wr Code,for he performance of the work for which this Permit is issued.
M ofkcr.Cn pees u Insunna artier end Policy num cr
Comer:JrJpf�, Policy No.:
CERTIFICATE OFEXEX ON FROM ORKERS'
COMPENSATION INSURANCE
rods section ncd not W completed Ifthe permit Is for one hundred dollars($100)
nr leu)
I certify met in Ne perr,,.a..or the work for which this Permit is issued.I,Intl not
employ any person in any muneran as In become subject 10 the Workefi Compdnsurtm - -
Law,of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this Oodfcne or Exemption,you should
rectum subject to the Workers Compenution provisions of the Labor Cotte,you most
Jz unhwith comply wimsuch poviainns or this Permit hall W dccmcd avckcd.
Z O CONSTRUCTION LENDING AG ENCY
1 hereby affirm that mere its construction lending agency for the Performance of
3' me wu k for which this permit i,issued(Sec.3097,Cu,C.)
:g1 P) Lenders Name
=z Lenders Addmu
U Q 1 cenify the 1 have sad this application and,tine ren the eWw infotmetiun is
U4 i~ correct.1 agree to comply with all city and county oNinancea and state laws miating to
C U building construction,and hereby aumorire repfeunidiwa of this city th enter upon the
W above-momma l proanly for introduce purposes.
gy (We)-;me to ave,indemnify and keep h rmless me City of Cupertino against
rA liabllitienjudgmeno,coats and expenses which Tlaccrue against said City
(„)z in consequence of the grants f anis re
^ APPLICANT UNDER DSA ILL COMP LTH ALL NON-POINT Issued by: Date
SOURCE REGUL
Re-roofs
Sig^ re of Applic o Oa
ARDOUS MA RIALS DISCLOSURE Type of Roof
Will mea and ser future huilding Occupant store or handle havarduus material
as dcOncd by tin upenino Municipal Code,Chapter 9.12.and the Hcallh and Safety
wc.Section 35533("77 All roofs shall be inspected prior to any roofing material being installed.
❑Y"
Will the applicant or Tutu building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
Sit hx,.Cm,air am se inmu dcftned by the Bay Area Air Quality Management all new materials for inspection.
mrlct7
❑Ycs ❑
I have teed the ha s materials requirements under Chapter 6.95 of the CalifnI,
nice HcaWffiSafclyC ccuons 255(75,255 ad155J4.Iundcrstand motif line Wiidi
docs not cortcn0y haw a tanan,than il' re t t u m only t
req mats which mUstem rt edor&Mcale to Signature of Applicant Date
Owner or aathorind agent Date All roof coverings to be Class"B"or better
it
CITY OF CUPERTINO
�(G.. 0 3//0702�
Of
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
3�� PZSooS
Building Address:
Owne •s Phone#:
Con actor, �n� & Phone: License#:
f-e 1.t � -G Su 7 ,31 s S
Contact: I Phone: Cupertino usi e License #:
Building Permit'Info: a
Bldg ❑ Elect Plumb ❑ Mech
Job Descri tion: I P��ce Awa S1 r\-g Le Sl dc-A w� U
S
Residential Commercial ❑
For Re�ssidential In�a llations:
Attic u 151 floor LJ 2nd floor❑
• Adhere 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,qf Project: Type of nstruc on: Occupancy group:
s
Strapped ❑ On Platform ❑ Bonded ❑ Sq. t. Floor Area:
New Location ❑ Replacement ❑
Qty. if a
2 A I' a IA 1' a I Fee ID Fee Descri tion Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
fm
BREMAIRHAN A/C Units <= 10, 000 cMECHANICAL
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 BUILDING