05050108 (2) CITY OFCUPERTINO :»P
BUILDING DIVISION PERMIT =CONTRA OR TNFURMATT0
BUILDING ADDRESS: A PERFECT CLIMATE PERMITNG05O5O108
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY FIT C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
repo LICENSED CONIItACTOR'S DECLARATION
r�2 1 mWroby.76 affirm Out 1 am of Me
Bu antler provisions;of Chapter 9(mmmensi Is edga� e$ rl tlO�
n< with Section 7IXIU)of Dlvidon5of the Butlnwand Profcuiuns Code,and mylicenmh FF
< in cull fortt and arc
5'�z uaense Cl Le.g ADD ASC
t Dau Conuaemr
ARCNITECrS DEC RA ON ^�
1 understand my plans shall be used As public records rvra
.;C Licensed Prufessional LIJ
OWNDECLARATION
ER-BUILDER DECLARN
1 i 1 hereby alBnn Nat I exempt from the ATIOroYl License Law for the
S:0 0 following mason.(Section 703 1.5,Business and Professions Cods:Any city or county
$ which requires a permit to construct,ober.Improve,demolish,nr repair any structure
prior m its issuance,also requires Me applicant for such permit to file a signed smmmem
<
MAL Wislicensed pursuant toMeprovisions ofMeContractor's lave Law(Chapter 9 Sq.Ft. Floor Area Valuation
B (commencing with Section 7000)of Division 5 of the Business and Professions Com)or
Nat he is exempt thcmfrom and me bub for the alleged asemptioo My violation of
Section 7071.5 by any applicant for a permit subjects de applicant An a civil penally of 3��gQ)0 Occupancy Type
Add mom than five hundred dollars(150)).
❑I,u mwmr of me pmpmy,m my employcu wed wgu u Oeb mlc empenadon.
will do the wurk,and immucture is notintentled ora@red mrwe(SAO.70".Business Required Inspections
and Professions Code:The Canmmmr's License Law door ml apply m e ns an owner of - Q p
property who builds or improv thereon.and who dws awh work himselr w duc ugh his
awn c nploye s.pmAded that such improvements me not Intended W offered fm tab,If.
however.Ne building or Improvement Is sold within am you of completion,Ne owner.
builder will have Me burden of proving that he did not build or Improve for purpose of
ale.).
0 1.as owner of the property,am exclusively contrasting with licensed anvacmn to
construct me pmjmt(Sec.7044,Business and Professions Code:)The Conmmtnr's Li-
cense law dors nes apply An an owner of properwho build,or improv thereon.red,
who concocts farmch projects with a contractor(s)licensed purl mm to the Comms:toYs
License Law.
0 lamesemptunderSec .B&PCformismuon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the folbawing declarations:
1 have and will maintain a Certificate afCAned a self-insure for WmkeM1Compen-
I.rk
an,u provided for by Section 5700 of the Labor Code,for the performance of the
for which this permit is issued.
I have and will maintain Workeei Compensation Insurance,u myuimd by Section
00of the Labor Code,far me perfotmame of de wok for which this permit is issued.
yWork7a/ c mpensatlomInsurance carie and Polwy((nqyrub tae:rtier.�(. Y Polity CJ�_
CECE FlTS OF Pf10N FROM WORKERS'
COMPENSATION INSURANCE
flab section need ret becomplemd Ifft permit is formic hundred dollars(SIM)
or less)
I certify mel in the performance of me work for which ml,permit is Issued,I shall not
employ any person in my mmmrso as to become subject to Me Worker(Compensation .
Lava of CalifmAia.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ceninau of Exemption,you should
become subject An me Worker's Compensation provisions of me tahnr Code,you mus
.,O forthwith comply with such provisions or this permit shall be dmmed rovnked. .
5 y CONSTRUCTION LENDING AGENCY '
[r I hcmby aDirm that them is a construction lending agency for the performance of
FCme work fur which this permit Is issued(Sec.7097,Civ.C.)
Ig1 Q Lender's Name
0z Lander's Address
U OF I certify ms I have rad this application sed sum mal the above information is
th '
D.U coma,'agree m comply wiall city and county ordinances and state laws; m
O building construction,and hereby summation representatives ofmis city to Amer upon me
Liz above-mentioned property fm Inspection purposes.
gL (We)agtm In ave.indemnify and kecp harmless the City of Cupertino against
rn lubilitlesJudgmenls,costs and expenses which may In any my accrue against mid City
U 7 in consequence of the Standing of this permit.
tom— APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SR EREGULATIONS. V
9 �&o Date
allaRe-roofs
t{wumal'APpliarranrano
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Oe appliant or future building occupant sore or bundle Nodous material
u defined by the Cupertino Municipal Cade.Chapef 9.12.and the Hcdm and Safety
Calc,Section 2335$07 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONO
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haurdous air contaminants u denned by the Bay AMA Air Quality Management all new materials for inspection.
is0m
0Yes ONu
1 ham mad the huadlws maerlatarequimmeno under Chapw6.9Sof de Califon
nb Hulce&SafayCodc,S.,U.25305,25577 aed255M.I undcruend msirt a building
Muss not currently hero a tenant,that It b my responsibility m notify Me occupant of the -
myu en which muslW mel ps r asuangeofa Cetl�late'f Ocie
�ti2Cw nl�!/7.1/ S iV r°} Signature of Applicant Date
Owner oradhortxetl a ret Dae All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
OCOF
Cupertino CA 95014
TelephFax(4088)77�3333
UEIINO
BuildingDe artment
JOB ADDRESS: . PE�r# Ole
� ^
OWNER'S NAME: e PHONE#( /-/02) a 6L
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: �a0 Date e
Signature
Please check applicable subcontractors and complete the following information
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
I
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC 5'
&UPERTINO PERMIT APPLICATION FORM
APN # Date:
3i a3o�5 -I�- os
Building Address:
1115 Ill C
Owner's Name: } Phone #:
3
ntractor: �KPhone: 'License #:
`- 3 I
Contact: Phone: Cupertino.Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb r❑ Mech ;i
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor E3 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 Construction: Occupancy group:
to
Strapped On Platform LJBonded LJSq.Ft. Floor Area:
New Location ❑ Replacement ❑
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
BRENI .IRHAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
l 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