06010144 r CITY OF CUPERTINO
BUILDING DIVISION PERMIT Wsomt"q'QQW N RMAT�ION,:k
BUILDING ADDRESS: A PERFECT CLIMATE ERMR"o_06010144
11063 BEL AIRE CT
OWNERS NAME: PEFAffI ISSUEDATE
HELEN BALABINE 10570 S DEANZA BLVD 01/26/20
06
NE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECTIENGINEFA BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
0 0 0
ucFNSF�mNrancloasDFcuannoN JobDescri ti n
rd u 1 hc,eby off ohm I m IRenad utdce Povisi«u a[Tamer 9(eommvcing
m thSatan 7")of Div Won 3 aft autioc.mid Ptausnvu Code,and my lkcmeu
InfuBfn dert REPLACE FURNACE a VV
733 L6'
qZ Ixensc Cl LSD L
Cmtranm e C
S ARCIIRECI'S DECLARATION
?of u I un0ctvnJ my p Ws shall be recd u pobac roads
ir o licc.d Pndasiatul / ,(
OW NFR-BUILDER DECLARATION /
I hrtby affirm thm I am ucmpt from the Conl,>,nors IJcmw for the b SOO�
no following mamn(Sauon TW S,Bus4w ud Pmfeasiom Cock:Any c'vY«cowry a7 , $3651
''$ which rcqultu a permit to eowrun-slurw
r,impte,dem.]i ,«mpYr my strucwm
—�^ priarm[B oonec.momgn the P.s. .roe such Pcr ..1.1ccr asLtN h'tcrN
EE�< Ilwhcls lkcmcd putwmt Inthept avWmuMNc Conuu:l«YlJ P,ccoti Chytta9 Sq. F[. Floor Area V�I/�� ���on
Y�$ (c,,, c13 ngwlthscctroln"NDlvuion3.ulcus vo,mdm Anymu Cao)or
a
��— SSmdon 7I0M M'my jtppl'�t fa perm tbutui forpnby tbetiPp�llcsl W.cull Wpration autyN
na mate mm nK wmdrod damn WWI.
r Occupancy'Type
❑L u awncr of the properly.a my vnpbYtta wW wwtea u Ihtr mW e«epmrvhn,
wiBW�wat.ad tee�u not lntcndcd orale f..*Ism TDN.Busircu Required Inspections
nui Profarims Code:The Cantnebfs License�mos.ot apply m m�of q
promy who buildsorITP,aKa threw.and wbo dos such wart hth if«through his
awn rmployas,provided thol such Imprczmenu art not inwu orafrr,1 for We.B.
bow .the MWlot orMprc ementutold wlthut arc yem of tamplWot Neawoer-
W iW will N,e th burden of MAng Nat he did nm bu1W or imprme for porphin of
ulcd.
I;u.wren oj th P(�.
70w nelaslrmr ma moo,i wile )The, mvumlan i-
carutran the pto)en Pply 7D6..Burd and Y wh"iLN Code)The,Comuuorl Li-
..
i
ttbtefcoweoue«applymm Ricco PopenY) locals«iWto lhu tcmn and,
who covtruv f«arch prolecn agth•conaaca«(s)lived purvuN u Ih Cwu.ctaf.
IsLJw.
l
❑ am esemP uWc,Set .BkPCf«thu wen '
tar Due
WORKERS COMPENSATION DECLARATIOY
1 brreby amrm udcr p®Ily of Per}uy,om a the followill dccuntana
1N.e and w111 mtlmain•cmlfteu ofCment to> f-iuurc f«WorWscmnpcm
lff�flih��
atheor which the Pamir u W wJ1 wlwin WO 'j Ccnmp m Inamac,u tequi by Smlmrth Mbar Cock.f«do pc,forma cc athc wart f«wh W 14Is Psmu u luocd
Wortcla�Cyvmpwuian Irumsaz torc W Pdiry m�mjh�r /�rtier: A'1 �`' Policy No.:�OY' �^Y�
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
rrbis con recd sten h caopW¢d Ifth pvmlt It Tonic luMmd colas(SIW)
«e .)
I tt fy WL In the PI(ormmce a the wort I«wblce the Pit u honmJ.I shall am
mopLW airy'fc min my mmocr m u W become subject to the Wort WCompeuatm
laws of California.Date
Applicml
NOTICE TO APPLICANT:If.ew mating the CetuBrne of a mpton,you should
become abj n to th Wm,cYs Campcwtion prtwaors of ITr Labor Code.Y.moa
wJ O forthwith mmply with such pmvitiau«the Permitshall be datmm
d tctcA
?� CONSTRUrnoN LRNDINGAGENCY
IhmbYdn iham iii uam!(SM ,Civ. atcrcy fv Jtc Prrarmmuof
C' > Ih wart(«which Nu pemtlluln«L(Sa.3W7,civ.Cd
dz lcrnl Name
=Z Ictderl Addrm
U O 1 mdfy Wat 1 lava rcae the ai,plicm.artd sue then the.bore ia«matiun u
"P ccc c I.gra m comply with 01 city mrd cowry ordinuccs artd sue un mlacot m
OU Wildill canartcton,Whcmby mtharin rcptuenwlrc of this city to cmc,elm th
0. .hove-menfi c F p.1y for I.KcWn perp..
(We)agme to um itdcmNfy and kap bmnl u the City ofcuper inn ag.im
.Fi N 11WIlda,juLgmcnts,cons and espenms wht wy to my my accue atalnn aid City
UZ In ewucquencr of th ttmtint a Ws P(molit-
APPLICANTIUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RCERU nONS.
Re-roofs
Sltnmurt or APPliaoVConlrtcur Dene
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIIItheCtrp n (M.ni hWldhigoavlvtuante«mc!th h otith sdS rlal
u cearcW hY the Cupenim MunWlpl Cock.Chafer 9.12.W IbC F1alN and Safny
udc,Sation 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will Ibe.pplimt or rmma buiWing aacupnl am rquipmml m�which If a roof is installed without firs[obtaining an inspection,I agree to remove
it havudmo air con hams u dermal by the Bay Aro Air Qu.litr MwN.L all new materials for inspection.
❑Yu
I have read the ha udtus mm,mi,rcrotremcro;umtr Chper 6,95 of Ih GInr- _
nu HalJtk Safety Codc,S voa 355it4m33am12553C.ywMfyd WrlfNc hof'
Jas hitcurtctW Nc•twrLL NU Ito mY rtgptulbORYmaWfy th oaupnt of cc
,qTnm moabonom iawmteeaI ccaiaaf Signature of Applicant Date
Ownc,maatnomm. ea aN All roof coverings to be Class"B"or better
s Community Development
0 Torre Avenue
O
Cupertino CA 014
Telephone(408) 777-3228
CITY 0, Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT / �/ O�
D� t # b
OWNER'S NAME: e PHONE # 6
GENERAL CONTRACTOR Cj(vvr,4--e FAX # b'—�761'—9,S-Yk
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
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
AW Tile
0
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
EUPEkTINO PERMIT APPLICATION FORM
APN # 16
6 �U Date: / `0
/
Building Address:
O,vner's Name: Phone #:
1n BO C O; ,O-
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License #:
Building Permit Info: (O
Bldg ❑ Elect ❑ Plumb 'El Mech
Job Description:
l CtC f--
Residential Commercial ❑
For Residential Insta tions:
Attic ❑ 1" floor 2nd floor ❑
dhere to nun set back requirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight (structural talcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningApproval Re uired ❑
Cost of Project: Type of Construction: Occupancy group:
3 X51. D-G
Strapped ❑ On Platform Bonded Sq.Ft. Floor Area:
New Location ❑ Re lacerrient
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFLJRN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAII2HAN 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