05090207 (2) CITY OF CUPERTINO +^
BUILDING DIVISION PERMIT r1.TION
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO.05090207
11650 UPLAND WAY
• OWNER'S NAME: PERMIT ISSUE DATE
TERESA RYSSEMUS 10570 S DEANZA B 09/29/2005
NE: SANITARY NO. CONTROL NO.
r
('408) 861-9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MEOCH
30o LICENSED CONTRACTOR'S DECLARATION Job Descrl tion
I hereby affirm Nat I am licensed under previsions of Chapter 9(commencing p
with Section 7000)ofDiviaion 3 of the Business and Profession Code.and my license u
7� in ruHforte an do If i 50 REPLACE FURNACE ,Q
z 10 4 CI I3c.x " r
j.oNeX% Camacmr G �/
g�gARCHTECEC
IT'S DLARATION //vv
a 1 understsnd my,plan shall k trades public records ('
> U
g Licensed Professional
g OWNEmBUILDER DECLARATION 'JO
2 1 hereby resum .lion Nei 1 ren exempt from the Cantncmrs Liana Law co the `O
p O following resume.(Saito]onstr t.altar. and Professions Code:Any city m county
S$i2 which requires a Permit re crnsuuct,attic,imfor such
demolish.t or repair any structureest ,��� 17 3 B
_zy thtrmiu issuance,
ensedpalmrequires theatela.of for suchpe er's Limae a.
< thahnumicnwit pursuant 70tH of Divioa of Nche SuacuMSLianxmon(Chapter Sq.Ft.Floor Area yValuation
O (cat he is exem with Section 70n d the Division 3 of the egad Students and on.Any
Com)on
Q�$
that he u exempt therefrom and the bola for Ik alleged exemption.Any violation of tJ'N
Section 7031.5 by my applicant for.permit subjects the applicant at a civil penalty ofr - OccupaddyApe
not more than Ow hundred dollars(550 ft
❑I,a owner of the property.army employees with wage u their mle compensAon,
willdolhewor6.andthe swctumbnoti.mMdaraRertdforsak(Sa.70M,Buircu Required Inspections
and Profession"Code:The Commcmes Liwan e Law donot e ns apply m an owner of q p
property who b W Ids n improves thereon,end who docs aoch work himself or through his
Man employees,provided thatsuch imparammnu arc main sled or offered foram.if,
however,Ne building or improvement is mid within ons yaw of compleuon,Ne owrur-
builder .will have the burden of proving that he did an,build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed cantraren to
construct the project(Sec.7044,Business and Profession Cade:)The Commuter U. ,
sae law does nut apply to an owns of property who Whiner improse,therem,and,
who contracts formch projeaa with a contractor(3)licensed pursuant m ft Conuacmra -
Lkeaelaw. -
❑lamesemptunderSec. ,B&PC for this won
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby atrium under pealty of perjury,aro of the following decimations:
1 haw and will maintain a Certificate of Conant to alf-iaum far WorkersCompm-
atian,as provided for by Section 3700 of the labor Cade.for the pafmmma of Ne
work for which this permit is ivied.
❑1 haw and will minors Workers Compensation Weaccom.as required by Section
3700 of Ne labm Code,for to performance of the work forwhich this permit is issued.
My Workes Compensation lnsursnce carrier and Policy number ace: ,/.,._
Cartiee Policy N.6: —
CERTIFICATE OF EXEMPTIONFRM WO KERS'
COMPENSATION INSURANCE
(This scrim meed net heompleud irthe permit is foroachundrW dollar(SIM)
or mss.)
I Cum(y that in the performmiec of the work for which this permit Is issued.I shall not
employ any person in my at bject to the workers'Compensation
Laws of California.Date
Applicmt
NOTICE TO APPLICANT:If,after making Nta CeNficaa of Exemption,you should
become Subject an the Workers Compensation provisions of the Labor Code,you mum
0z forthwith comply with Inch pavolons or this permit shall k damell revoked.
z0 CONSTRUCTION LENDING AGENCY
(~� Ikrehy affirm Wt Vert is a mosuuction undingsgemy for the performance of
G'
the winkfor which Nu permit u 097
issued(Sec.3 ,Civ.C.)
W� A Ietders Name .
Z Lenders Addw
U 0 1 certify that I Mw rid this application and sum that the show information Is
ly P comm I agree as comply with all city and county ordinances and Tum hems claung to
0U Wilding Caatmction,and hereby,uhoria representatives of this city to mor open tie
W move-mentiorad Property for inspection Pugases
LL (We)agree he am,indemnify and lump humtrss Uta City of Cupertino against
rA liabilities,judgments,tofu and expanses which may in my way acme gaiat said City
in caaegunne of the grunting of NU Permit.
^ APPLICANT PKDPRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
C� Re-roofs
Signature,of ApplinnInConumrm D,u
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupmt mac m NMIc locumd a material
iamlldefend by tic Cupertino Municipal Cob.Chapter 9.13.and the Health and Safety
.Serum 25533(a)± �No❑YG All roofs shall be inspected prior to any roofing material being installed.
will tic applicant or future Wilding occupant use equipment or devlcnwhich If a roof is installed without first obtaining an inspection,I agree to remove
ha ndous air cmumianu u rimd by the Bay Area Air Quality Maesgemcnt all new materials for inspection.
District?❑Yes u
1 have rotl the hmudms materials requirements under Chapter 6.95 of the Califer.
nit Health&SafetyCode,Seeuau 25505,25533 and 25534.1 unmanned that lfNe Wilding
does an,currently have•neutron.that it is my responsibility m notify the occupant of the
now h k mina= f.catirkmco m Signature of Applicant Date
04 lir ar,whorimd,em Dau
All roof coverings to be Class"B"or better
Community Development
10300 Torn Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
1 1n50 U \ UJLL D 2.0'7
OWNER'S NAME: QX PHONE # 8 - - 5 ,k-6
GENERAL CONTRACTOR 1 0. FAX # �d
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
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating ']j,3159
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO g
FURNACE/AC
WUPEkTINO PERMIT APPLICATION FORM
APN # 1 3 / / -l? b Date:
c� Z
Building Address:
O er's Name: Phone #:
Co actor: U Phone- License #:
Ott ct, 8bt- D31S-igv
Contact: Phone: Cupertino Business License#:
� D£f-8'6/-9cs'fcs
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech LW
Job Description:
&e. OICILmd QC_'e-
Residential I Commercial ❑
For Residential Installations:
Attic ❑ Ig` floor 92nd 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 ❑
st of Project: Type of Construction: Occupancy group:
J D .0 o
Strapped On Platform Bonded ❑ Sq.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
BREMAIRHAN 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