05040177 (2) CITY OF CUPERTINO `^^"r'.;�, ✓:r'>th`�"�s' °'r't`"<)`
BUILDING DIVISION PERMIT C10N RU TOR—N� ANE
BUILDING ADDRESS: A PERFECT CLIMATE ......05040177
OW NER'S NAME: PERMIT ISSUE DATE
4'1
ONE: SANITARY O. CONTROL NO.
ARCHDEC AENGINEER: BUILDING PERMIT INFO
BLDO ELECT 0 t� PLUMB MECH
D O
30p LICENSED CONTRACTOR'S DECLARATION 7obDescription
�v I hereby affirm that 1 am licensed Business
under pmNuou of Chapter 9(commencing
F I L E
d with Section 7000)of Division S of the andviedul of Cada mdmy commenci is
in full forte and —� I FURNACE REPLACEMENT
j n Z Liccnto CI - Lic.N
n a Dam Contractor
ARCHITECTS DECLARATION ,,/
v�e,u I undrntand my plane shall be used ss puhilc rtrnrda h/ — 2005
g0� Licensed Professional
OWNER-exempt fa DECLARATION
i y I hereby AEtrou o n 1 em exempt from Gate CanusctCo Ucrase Law for the,
0 o following mason.(Section Fat 1.ra Bushel. and Prr,kauam Code:Any city or county
$ which requires•permit m ennsumt umr,improve,demolW,m repair ay—IMI
prior to its issue.,alar,requices the applicant for such Permit M rile at signed statement
g < that he B licensed pursuant in the prevision of do Conanotah lJcaruc Law(Chapter 9 Sq. Ft. Floor Area Valuation
g (commencing with Section 7000)of Division 3 of the Business and Prnfeuinu Code)or
Nat he la exempt therefrom and the but,for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 ft(;r0 0 Occupancy Type
not mom men five hundred dollars($500)•
❑1,As owner of the property,or my employees with"gnu their sole campenudon,
will do the work,and mestmcwre is not In¢nded An offered forsale(Sec.7044.Bushe s
and Pm(esslons Cade:The Commutes uses Ltcenu Lew does ant apply to an owner of Required Inspections
property who Wilds or(mprews the r s n,and who daes,ucb wart himself ar through his
awn employes,provided that such improvements art not intended"arfesud for ale.If.
bowever,the Wilding or improvement Is sold within ane year ofeamptetion.the owner.
builder will have the balers of pmving drum be did not build m improv for purpose of
tale.).
❑1,As owner of the property,am exclusively contracting with licensed contractors to
coast.,the project(Sec.7014,Business sad Profession Cade:)The Commences Li.
cense Law does not apply to an owner of property who Wilds or improwe icemen,and
who contract,for such projects with a con nctor(s)licensed pursuant a the Contractor',
License taw. .
❑l am exempt under Sec. .B At P C for this name
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under pommy of perjury oro or the follow.,declaration:
1 haw and will maintain•Cerdficate of Consort to self-insom for Warkee,Comport.
sedan.as provided far by Secdon 5700 of the Labor Code,for the perfnmentte of the
work for which this permit is issued. . .
❑1 have and will maintain Wmkces Compensation insurance.M required by Section ,
3700 of the Lab.Code,for the part...ca of the work far which this permit Is lotted.
My War e,Compensation insurance carrier and Paltry nu berate:
Carrie VAP ✓A Poliry No.:�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rub sect m reed an,mcanplemd tithe permit Is foranchundred&Ilm(Slm)
or kr,.)
1 reality met in the performance of the work for which this Permit is Word,I Nell nnn
employ any person in my mamcr an As to became subjecto the Worts'Compensa Ion
Laws of Csliforom.Data
Applicant
NOTICE TO APPLICANT.If.after making nils Certificate of Exemption,you should
became subject m the Worker's Compensation provisions of the labor Code.you must '
wJ Q forthwith comply with such provisions at this permit shall be deemed overt
Z ► CONSTRUCTION LENDING AGENCY
F' I hemby Ailuro dm them is a construction leading agency for the performance of
G'> the work for which this permit is issued(Sec.3097.Cih,C.)
ELaborer,Name
SL.z 1<ndees Address
U G I cenify that I haw read this application and sum that the aWw information is
{>ti P Correct,I agree at comply with all city and county ordinanes and sum laws misting to
�U building commotion,and hereby uthader representatives of this city to enter upon the
W above-mentioned pmpeny for Inspection purposes.
(ls (We)agree to taw,indemnify and keep harmless the City or Cupertino against
M liabilities,Judgments,casts And capensee which may in Any way seem.Agent Mid City
U 7 In consequence of the Senting of this permlt.
r� AP LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S REGULATIONS, ,,/
r-eat Z8 Re-roofs
Signature of ApplinnmComector Data
HAZARDOUS MATERI LS DISCLOSURE Type of Roof
Will the applinm.futum Wilding aeeupatnom"handle hi usdou materid
As defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
aura,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes PNo
Will the Applicant or roan building occupant aM equipment or devices which .If a roof is installed without first obtaining an inspection,I agree IO remove
I.i.dtars
mit hummus air contaminants a defmod by the Bey Area Air Quality Management all new materials for inspection.
istrict] /
Gees ®Nu
I haw mad the hnaNrm_mamriab rtquircmemsund"Chapmr6.95of me califor.
HMIO'SafctyCodo.Swao 25505,25533md25534.1undemm�dmulftheWilding
not currently haw a basal,ton u or,It my sonthilitym mnify the eccapanthet or yui mcnuwhichmuubemetpdormiuuancaofaCeNOcam faenpanry, Signature of Applicant Date'
A 2�— � All roof coverings to be Class"B"or better
Owner or authorized agent Dam
CITY OF CUPERTINO 7
!1 FURNACE/AC
WUPEP,TINO PERMIT APPLICATION FORM
APN #
Date: 2,2 J 6S-
Building Address:
kc1q:5 Lt
t� r
O per's Name: Phone#:
D1 i E A a72,Gpntr
TCWtor: 0Ai 491 ?( (_ S�fS License : nZ 31S $
ontact: l� Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
yVll?tez--)
Residential Commercial ❑
For Re idential Installations:
Attic M I" floor ❑ 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 of Project Type of Cvorystruction: Occupancy group:
Strapped El On Platform LJ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
�. BREMAIRI-IAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERNUTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING