03070153 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT *CONTRACTOR°INFORMATION
'Pa '. tom ', o,
BUILDING ADDRESS A PERFECT CLIMATE PERMIT"03070153
0465 1211glop-TIRW P-1-7
a OWNER'S NAME: 10570 S DEANZA BLVD PERMIT ISSUE DATE
TAY PRESTON
NE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
I� 0 0
LICENSED CONTRACTOR'S DECLARATION
z I hereby air,,m that 1 am licensed[under provisions of Chapter 9(commencing Job Description
2.ae
i with Section 7lM)) !Division 3 of me Business and Profession.SC�ndesagdmylicenuis Dz
in full forte and a !/
its
zD= Littnu Class Lic.X ��✓ a REPLACE FURNACE & A/C '��+��
t2❑ Date Comm�or
',]` ARC CTS DECLAR T ds 1
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1 usWemand my plans echo the oma as pantie mebms U` 3 Q 203
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3 m t Liccrued Poor...bit p
$.OS OWNER-BUILDER DECLARATION 1D�J'LD���.5i
d a Z I hereby affirm that I am exempt from the Contractor's License law for the
0 o following uo on.(Section 703 1.5,Business and Professions Code:Any city or county
x m f which requires a permit to consumer,alter,morrow,demolish,or repair any sBuch m _
Fiy poor In its iuuantt.alsu rcquius the applicantforsuch Permit to file asiprodsulemcnt
a that he is licensed pursuanotheprovisionsoftheContractor''sLicenseLow(Chapter9 Sq. Ft. Floor Area Valuation
pursuant
At (commencing with Section 7IX0)of Division 3 of the Business and Professions Code)or
E 3— that he is exempt thcteffom end Ne basis for Ne alleged exemption.Any violation of 36911034 . 00
Section 7031.5 by any applicant for a Permit subjects the applicam to a civil penalty of APN Number Occu ane T e
not more Nen Rve hundred dollars(5500). p y yp
I,as owner or the property,or my employees with wage.as their able compensation,
will do one work.and the shonum is not intended or offered for sale(Sm.7014.Business — ROUGHb§p Cti On$
and Professions Code:The Comm�ors License Law Law does not apply in owner of 3 01
propenywhe builds°,improves thereon,and who duessuch work himulfor through his 303 - ROUGH M CHANI�AL
own employees,pmvided that such improvements are not intended or offered for sale.If. 304 — ROUGH ELECTRICAL
however,Ne building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving mat he did not build or improve for purpose of 505 - FINAL ELECTRICAL
.1,J.
0 1,as owner of the property,am exclusively contracting with licensed conoacton to 507 - FINAL PLUMBING
consumer the project(Sec.704,Business and Professions Codes:)The Contractor's Li 508 — FINAL MECHANICAL
cane law does not apply to an owner of progeny who builds or improves thereon.and
who contracts for such projects with a contr ctoms)licensed pursuant tome Contractor'a
Liccnm law.
❑I am exempt under Sec. B h P C for Mean
Own Dau
WORKER'S COMPENSATION DECLARATION
1 hereby alrum under Penalty of perjury one of the following declarations:
I have and will maintain a Croffle oof Consent to self-insumfor Worker's Compen-
somm.as provided for by Section 37M of the labor Code,for the performance of the
work for which his permit is issued.
1 have and will maintain Workers Comiummunion Insurance,as requited by Section
of the tabor Code,for Nes performance of the work for which this Permit i.issued.
111 y orker'a pensatmn Insulin a canicr end PMey nu rbe ase:
Cartier. Policy No.:
CE I I E OF EAEM ON FROM W
COMPENSATI INSURANCE
(this aectinn need not he completed if the permit is forone hundmd dollars($IMI
less.)
I"miry that in the performance lir the work for which this permit is issued,l shall not
employ any person in any manner sat as to become subject o the WorkersCompensation
Laws or California.Dam
Applicant
NOTICE TO APPLICANT:If,aper making this CcniBcne of ExcmpJon,you should
become subject to the Worker's Compensation previsions of the labor Codc,you must
.J ,Z, fonhwl Ib comply with such provisions or this Permit shall he deemed revoked.
Z0 CONSTRUCTION LENDING AGENCY
I hereby affirm that more is a conshaaion lending agency for the Performance of
the work for which this permit is issued(Sec.3097.Civ,C.)
QLender's Name
= z L emm,'s Address
t.7 0 1 certify that 1 have read this application and sum to,the above information is
O VCOMM.l agree to comply with all city and county ordinances and sure laws relating"
building consume on.and hereby authorin upresen ivesofthiscirym mcrupnnthe
ahove-memionc M.
for inspection putpou
H (We)ag m save,indemnify and ku I the City of C nim,against
Z incoises,judg nut granting
uind of the swhi May anyway eccmc ainatsaid City
Uz in mnuqucn (Ihc greening oflhisper '. I
^ APPLICA NDE TANDS AI" ILL PLY WITH A NO -POI Issued by: Date
SOURC EG LATI S.
Re-roofs
Signawrc ofA plies V oro ter rte
A DOUS ATERIALS DISCLOSURE Type of Roof
Will Or ap icam sir forum ilJing occupant sore or M1endle hazardous material
as definca by h upcnino Mu 'pal Cock.Chapter 9.12,and me Health and Safety
Codc.Scnion 532(a)?
E]Yes No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or forum BdingOccupant use equipment or device.which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air omenerm az fined by ma Bay Area Air Quality Management
islriell all new materials for inspection.
0 Yes
I have mad me harafdous mamri qui enBunde,Chxpmr6.95ofthe Califnf-
motHeaWSSafny ,Sceduns25505,25533 25534.1 undcrsund mat it d¢Wilding
does net only a a te ant,mar it is my s Mohibly At notify the Keuparo of the
rcyuimm n¢w h un met prior of is ce ra CeniOcat of Occu
Signature of Applicant Date
O-rl,.1 rommi,roWero D„e All roof coverings to be Class"B”or better
I%. CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN # (oq I Date: '7 '9
/,)3
Building Address:
Owner's e: Phone #:
Contracto License #:
I �a
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Descriptio ) LWN��Q j
Residential 'C` Commercial ❑�l� �- l
For Residential Installations:
Attic ❑ 151 floor ❑ 2nd floor ❑
Adhere to min set back requirement❑
• For Commercial Installations:
Replacement same weight ❑ Additional weight(structural talcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cos of Project: ' I T of Con Ctr action: Occu ncroup,
Strapped On Platform �yBondeed Sq.Ft. FI or Area:
New Location ❑ Re lacement�`\
Qty. if
App ' a 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
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
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