03080063 (2) CITY OR CUPEI2'1'INO - `
BUILDING DIVISION PERMIT 4'CONTRACTON0RiINFORMATI
�. _ON.�
t OUILDINGADORES: PERMITN
PERFECT CLIMATE 00308OO63
464 RQLLTNGnE,1.1, DR
OWNER'S NAME: 10570 S DEANZA BLVD PERMITMUEDATE
YU BEN AND LINDA B
oN1:. (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ioo LICENSED CONTRACTOR'S DECLARATION
mF 1 hereby affirm.bat 1 am lift and under provisions of Chapter 9 tommcneing - Job Description
?Zr3 with Section 7NM)uI Division 3 of NC Busiwas.ad Professions Code,and my license is
+« Lilullmhf.meontl IgBb REPLACE FURNACE & ADD A/C
License Ca Vl../ Lic.N
�Fp Date TSDECr �1�Q�B E®
e wwwn M HITELTS DECLARATION
IION 111 b
t E< I understand my plans shall M used as public records
at
`;tat Lia°nmdprofaai°ata AUG 2 12003
OWNER-BUILDER DECLARATION
< I hereby affirm that 1 am exempt from thc Contractor's License Low for the
00 falbovin,moron.(Section 7131.5,Business and Professions Code:Any city or county
`{2 which requires a permit to construct,since,improve,demolish,or repair any structure
poor to its issuance.also M,Rnmi the applicant for such permit to file a signed statement
¢ < Ihal he is licensed pursuant to the,previsions of the Comms:lur's License Law(Chapter 9 Sq. t. DOr res ra Valuation
d�th (commencing with Section 7000)of Diviaimn 3 of the Business and Professions Code)or
Nat he is erompt therefrom and the buts for If.alleged exemption.Any violation of 35931062 . 00
Swilon 7031.5 by any applicant for 5 permit subjects the applicant or a civil penalty of APN Number Occupancy Type
not mom than five hundred unite..(5500).
U I,as owner of the progeny,or my employees with wags a their role compensation.
will do she work,and the smenum is not intended of offered fanal.(See.7044,Business — as
[J
and Professions Code:The Commoner Littrva Law docs not apply to an swan.of 3 03 — ROUGH Llo
property who builds or improves thereon,and whodoes such work himself.,through his
own empmyea provided that such impmvemenu are not intended or offered formic,If, 304 — ROUGH ELECTRICAL
however,he building or improvement is sold within am yead orcompielion,the owner-
builder will have dra burden of proving Nat he did not build at improve for purpose of 501 -- FINAL ELECTRICAL ENERGY
sale')' 502 - FINAL PLUMBING ENERGY
01,as owner of the pmpeny.am exclusively contacting wish licensed convenors to 503 - FINAL MECHANICAL ENERGY
construct the project(Sec.7044,Bualfw.and Professions Code:)The Contractor.Li
mase law does not apply to an owner of property who buildit or lmprovs daemon,and, 505 — FINAL ELECTRICAL
who contracts for such projects with a contractor(s)licensed pursuant to the Cofactor's
L1canm L.w. 507 - FINAL PLUMBING
❑ 1.ammplunderSee. .B&PC forOurfoods 508 - FINAL MECHANICAL
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of Nrjuty one of the following declarations:
I hew end will maintain a Certificateof Consenuo coif-usum(m Worker.Compen-
sation,m provided for by Section 37M of the Labor Code,for Ne performance of the
work for which this permit is issued.
ban and will maintain Worker's Compensation Insurance,az required by Section
37 of the Labor Code.for the performance of Ne work for which this permit is issued. '
My Worker'' C�mtcosation lnsu nee artier end Policy If0.
Croom Policy No.:
CERTIFICATEOFEK ON FROM
COMPENSATONINSURANCE
(Thismnim wed not be eomuctcd if the permit is formic hundred dollen(SIa)
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any pcount in any manner an as to become Subject o the WONMM Campeasadan -
Law.of California.Date
Applicant
NOTICE TO APPLICANT:If,after making ON Ccniftcam of Escmption,you thoulu
become subject to the Worker's Compensation provisions Of the labor Code,you must
wJZ forth with comply with such provisions or this permit shall as deemed revoked.
ZO CONSTRUCD ON LEN DING AGENCY
E" I hereby affirm that there Is a comtructionlending agency for the performnmec of
a > the work for which this permit is issued(Sec.709.Civ.C.)
LLl Q Lenders Name
D z Lender's Addam
U C I certify tha1l have rood this applienion and tote that Nc above information is
Ly F cones.l mctl pro ms
)ogre m veharmless agree ply with all city and county ordinances and sate laws slating m
O U building con cion, ed hereby authoriserepremmatives OfNie city tocnter upon the
ho
r [S7 avemcn ty for inspection purpoVY
( r indemnity and keep she City of Cupertino against
ti raj, liabilities Judgment oskaandexpenses which may in any way accrue agaimisaid City
U Z APPLIC nccU(1 ERS ung Lhis Permit.
AND WILL COMPLY WITH ALL NON P INT Issued by: Date 3
i
SO E ' ATIONS.
L Re-roofs
gnat., fApp can tractor Da
HA2A OUS M OX ISCLOSURE l Type of Roof
Will shca plicamne t Occu ammo.and to HeaNummamtlal
az acfinctl by tine
nine ipel,� apmr 9.13,and the Health amu Safety
sue.seeien Ys zs5 07 u All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ter vecc
r ing occupant use use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hamolous air cora ml not cf cd by the Bay Area Air Quality Management all new materials for inspection.
District
❑Ys
I have sad Me a steamismenu under Chapter&95.f the Calif.,.
iia Health&Safclyc mat ,255 an 2534.1 onderaand Nat if the building
does not cumemly have e n is my s ility 1e,fully t u and of LIF
requirements which mu 1 'o wise of Cenlfmamo m ce. Signature of Applicant Date
owner or sum atl en on, All roof coverings to be Class "B" or better
G CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN# ' Cl ' 7 Date:
Buildin dress:/ J
190)
1 �l
Owner' ame: Phone #:
10-�31s
Contrac or: racf I Licensa
airl
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description: ecgtc 9 - e v-\ \A
Residential Commercial ❑
For Residentild Installations:
Attic ❑ 1" floor ❑ 2"d 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 of Project: Type of C nstruction: Occu aicy group:
1
Strapped U On Platform LJ Bonded Sq.Ft. Floor Area:
New Location ❑ Re laceme
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 cfm 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 BUILDING
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