03090014 (2) CITY OF CUPEWI'INO ash?' n7T-- s ^�+: m'
Bun.Dmc rnvlsloN PERMITCONTRACTOR INFORMATION•w�.
BUILDING ADDRESS: _ A PERFECT CLIMATE PERMIT"03090014
?171_111C) qTTATERADW A17
R'S NAME: 10570 S DEANZA BLVD PERMTTISSUEDATE
ONE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELER PLUMB MECH
0 0 0 0
!00 LICENSED CONTRACTOR'S DECLARATION Job Description
I U I ion 70 affirm Nn I am httacd under and
of Chapmr 9(commencing -
with Sermon 71MA17 of Division 3 of Ne Business and Profcainm Code,and my license is
�nZin WBmrc`and S EPLACE FURNACE—A/C
LiccnsC Contract.,
FIN
!��Gan DECLARATION _ vALED
££ ARCHITECTS DECLARAT N
l w U 1 undersand my plain shall he used as publicrecordsierecords
sQ Licensed Pnrlocations] SEP 1 0 2003
OW NER-BUILDER DECLARATION
3<f 1 hereby affirm that 1 em exempt from the Contractor's License Law for the
o O following reason.(Section 7131.5,Business and Professions Code:Any city or county ��Y/�
'NG
<3 which requires a Permit m construct,alter,improve,demolish,no repair any stmaum
prior to its issuance.also reclaims the applicant for such Permit to file s signed anmmenl
< that he is licensed pursuant in the provision of the Contractor's License Law(Chepmr9 Sq. Ft. Floor Area Valuation
2€� (commencing with Section 7")or Division 3 of the Business and Professions Code)or
that he Is exempt therefrom and the basis for the alleged exemption.Any violation of 36939006 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APNNber Occupancy Type
—' ant mere man five hundred dollars($500). - - - - um .. - --- - .. P Y YP
01,as owner or the property,or my employees with wages as their sole compensation, T77y7p 7�T
will do the work.and Ne structure is not n
intended or offered foale(Sm.7014,Business — yg(� �5 Ctlons
and Professions Code:The Contractor's Limnae Law docs not apply to an owner of
pmpertywbo builds orimpmves therepn,and who does such work himself ormrougfi his 303 - ROUGH M CHANI AL
own employees,provided that such improvements are not intended or offend for sale.If, 304 — ROUGH ELECTRICAL
however,Ne building or improvement is sold within one year of completion,are owner-
builderwillhavemeburdenofprovingthatMdidnotbuildorimprovforpurposeof 505 - FINAL ELECTRICAL
ill`')' 507 - FINAL PLUMBING
❑Las owner of ct property,em Business
connectingfesss with licensed contractors to - --- _.
ceasweldoes the not aSec.oinOwameaanddywhooads or iproe;theron,Li- 508 — FINAL MECHANICAL
cense law docs not apply m an owner of progeny who builds or improves menton,and
whoafor such projects with a convano(q licensed m th
d pune Contractor's
License
Law.
❑lam exempt under Sec. ,B&PCfor this reason
I Data
WORKER'S COMPENSATION DECLARATION
1 hereby arm under penalty of perjury one of de following declarations:
1 ban and will maintain a Certificate of Coacnt to self-insure for Worker's Com ppn.
Odicn,as provided for by Section 3700 of the Lehr Code,far the peRmmantt of the - .. .
work for which this permit is issued.
X1 have and will maintain Worker's Compensation Insurance,a required by Section
of the labor Code,for the performance of the work for which this Permit is issued.
My Worker's Cam rasa. Insunntt art. and Policy number art:
Cartier. Policy No.: FS I�/f
CERTIFI ATE OFE PTION FROM WORKERS'
COMPEN.ATION INSURANCE
(This section reed not becomPlemd Btie Permit is for one hundred dollars(5100)
or less.)
1 certify that in me perromercc of the work for which this permit is issued.I shall not ..
employ any Person in any manner an a to Became subject to the Widen'Compcnsadnn
Laws of California.Data
Applicant ,
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject or the Worker's Compensation provisions of the Labor Cum,you must
O forthwith comply with such provisions or this permit shall he deemed revoked.
�'� CONSTRUCTION LENDING AGENCY
1 hereby affirm that mere its construction lending agency for the raofomunce of
$ the work for which this permit is issued(Sec.3097,Ci¢Q
Q Undoes Name .
7 Z builder's Addrcu
J Q 1 modify Nu I have read this application and sate that lie above inform tlun is
iF comma.l agree to comply with all city and county onAnances and sort laws orating to
0U aWye-gcoionedon,and for byeuthome rtprncnutivaofthis city mcmv upon the
W shove-mcmiuncd pmpeny foriaPection s.
r (We)ogre ave.I'hard ify keep Ica the City of Cupanmo agalat
h I;abilitiesA� ;11�hl'
udts,coats and cape cs whichm yin any way accrue againstsaid City
J7 iingoft sperm'
r1• ANO AN IL OMPLY WITH LL N-P01 T Issued by: Date />A
e-roofs 14
Sign uurc IAppimant/Ca for Oal
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar fuwre building occupant non er handle haardous mamrial
a defined by the Cupenino ni pal Code.Chapmr 9.12,and the Health and Safely
Secdon]5512(01 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will me applicant nr f.%
b Id ng.-Pont sae egwpment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit havafdous air conamimnts u ollard by the Bay Ama Air Quality Management all new materials for inspection.
District?
❑Ye.
I ad th!�A ls requirements under Chapmr 6.95oftheCalifm-
maHeal &S myC .25533and25534.1underst dthasifthc building
does not'u Ily has my respoaihilily to nodi the cupan of therequire whichisousemof.comficam c p Signature of Applicant Date '
owners ion ri,edagcnt at All roof coverings to be Class"B"or better
CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN # �! _�„ Date:
Building Address• O
Ownersa. 4 Phpge #:
Contr •to . \ � � License
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description: \C�Qe 04igA AeAL
ResidentialIK Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural talcs) ❑
Struct Tio1nsTequired for new installation ❑
N installation Plannin ` roval Required
st of Project: —�S Type of Construction: Occupancy g( ( 0 1 CO-% . r p:
r
Straplied Li On Plat rm onded Sq.Ft. 1 or Area:
ocati ❑ Re lacement El
Q if
A liqAbFee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 efm 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