04030128 CITY OF CUPERTINO
BUILDING DIVISION PERMIT t CONTRACTOR INFORMATION ';A
BUILDING ADDRESS: A PERFECT CLIMATE 111114904030128OWNER'S NAME: PERMIT ISSUE DATE
EMILY WU
ONE:
SANITARYNO. CONTROL NO.
408 861-9c;45 I
ARCHITECTfENGINEER:
6 -
ARCHITECrfENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
M-21 P
0 0
LICENSED CONTRACTOR'S DECLARATION Job Descri Io
s u C I hereby affirm Nes I am de
licensed unr provisions of Chapter 9(commencing
!¢m with section 70fk)of Divisiot3ofthe Business fc s ndmylicenmis
ufuBrmexmd e e J 2 NEW A/C UNITS MAR 1 7 2004
2 License Class Lic.N
Dalc Ca u-1-1
ARCHITECT'S DECLARATION
�i¢< 1 tndermand my plansshall he used.puldie reeafda BUILDING M B mtl
o G Licensed Proressiovl
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law far the
00 following somec
e.(section 7031.5,Busies and Pmrevsium county Code:Any city or
K m�i which mquir a .it to conn ucl,altar.improve,demolish,nr.,.it any structure
m—'^ prior to its issuance,also inquires the applicant for such Permit m file a signed statement
that he h Contractor's LJ¢
licensed purent to the proviaiov of the Contractor's Law(Chaptar9 Sq. Fl. Floor Area Valuation
a (commencing with Section 7")of Division 3 of the Business and Professions Cm4)or
Ran be u exempt therefrom and she basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subiccs the applicant to a civil penalty of 3 et00 Occupancy Type
not more than five hundred dollars($500).
❑Las owner or Ne Propsny,or my cmploycv wish wage as Heir talc compensation,
will do the work,and the structure is notin anded ora@red forsale(Sec.7061,Business
and Professions Cade:The ConuxsaYs License law dams nos apply m sa owner of Required Inspections
property who builds orimprovas thereon,and who does such work himself orthrough his
awn employees.provided rimemeh improvements tie not inuiWcd ooRered formic.IL
however,the building or improvement is sold within one year of completion.the Owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,as scone!of Ne property,am exclusively corseting with licensed convectors to
concoct the Project(Sec.7614.Business and Professions Cade:)The Contractors U
cue law docs not apply to an owner of property who Wilds or improves therm n,and,
who contracts for such projects with a con rsamr(q licensed pursuant to the Convanm's
L¢cnm law.
❑I am exempt under See .B&PC for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pe rahy of perjury 0.of thc following declarations:
1 have and will armunin a Certificate of Covent to self-itsum for WmtetsCompen-
sa ioe..provided for by section 3700 of the IaWr Code,far R.perform..of de
work for which this permit is issued.
❑1 have and will maintain Workces Compensation Insurance,as required by Section
3700 or me Labor Code,for the perrormance of the work for which this Permit is issued.
My Workct's Contrevauoo Ins11u.nna carrier and Policy number am:
Carrier.
� �q
Carrier.yt't 10 r.��/ITLI/l t// Policy NO.:_/)((J�IyH
CERTIFlCA OTE F�EXEMPITONFROM WORKERS'
COMPENSATION INSURANCE
(This scum rued not W completed!if Ne Permit Is fare.hundred dollars($1107)
or less.)
1 cendfy Nat in the performance of the work for which this Permit is issued,I stall not
employ any person in any manner m as or become subject o the Workeri Compensation
Laws of California.Dam
Applivans
NOTICE TO APPLICANT:IL atter making this Cmifrcam of Exemption,you should
become subject R,the Worker's Campvvation Provisions of the Labor Code,you most
.,z roMwith comply with men provisions or this ar d"hall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
-
'r^r I hereby affirm Nat dere is a construction lending agency for the perfoean.of
G' the work for which this Permit u issued(Sec.3097,Civ.C.)
W QLender's Name
6. Lender's Address
D
J 0 T certify Nat I have read Nis appliesuon and sae that the move inromrs utur is
D. F career,1 agree to comply with all city and county ordinances and sus laws relating to
O V building contraction.and hereby authorire repmxnutim of this city to enter upon tie
W aove-menti...d property for insfcctlon purposes
(We)agree to save,index,ry and keep harmless de City Of Callencs against
Iiebiliu( j) gren1....and expcvuwhim may inmy ss the qty of apinstsild City (_U)
U in consequence of the gaming of this it.
APPLICANT UNDERSTANggq��{A ILL COMP Y WITH ALL N-POINT. ssued by:9 Date
SOl1�CE RFjfiiULy3TlONS. �1
Ilbb �lyjlic uCm /y4 - 'lVI Re-roofs
Si vert of ApplinnUCon�crDr \ 52
Date
�a HAZARDOUS MATERIALS DISC URE U Type of Roof
Willtheapplivantorralure Wildingoceupantstomohandlehwa ousmawdal
as defined by the Cupertino MumbjpaFEvde;Chapter 9.12,and the Health and Safety
ads.Section 25532(a) / All roofs shall be inspected prior to an roofing material being
/ ❑Yes ❑NO P P Y ginstalled.
1 Will me appliance or future Wilding Occupant Ire equipmam or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it havardav it came., ons u r M't1the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes No
I have mo de WraNmsmaerials ¢mens un derChaper6.95ofthe Caltrar
ria Hcabb&Sxfery(;,ode.Seetimss2 5,2 3and2553i.lumkmhxmddwsirthc ilding
docs d t o tans is y reaponsinility toemly the[up t f
req mU n m xmet ' eta : �aracedB earoc.l.. cure of Applicant Date
ow att'om daglentt .DDmta All roof coverings to be Class"B"or better
aamw Community Development
10300 Torre Avenue
IZJ Cupertino CA 95014
Telephone(408) 777-3228
�
CITY OF Fax(408) 777-3333 UPERTINO
Building De artment
JOB ADDRESS;-7 � 5 T #
OWNER'S NAME: e7vvn� \ vJ J PHONE # Ao• c6U I- q
GENERAL CONTRACTOR:
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
Tile �^
Owner/Contractor Signatu
e Date
=� CITY OF CUPERTINO
CCS FURNACE/ACSC o3 � /
UPERTb
INO PERMIT APPLICATION FORM
APN # 35` ?�r 0 C- ?/ Date: 3 , � 1-
� t _I
BuipV
4inpT�ddres D (& W a, C , I ; �� (�
Owne��Nv" , J\ J lel/ J Phone-9: ,7- I -I
Covirrec C � tmcl� 7
PhoneOg $(p( - 0[5g5 Ln?/,3 1,5
Contact: Phone`s Cupertin Busine s License #:
Building ermit fo:
i
Bid • ❑ - ec ❑ Plumlze4 )
M O
Job esc intion:
all �e�
Residential [�— Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2nd floor❑
Adhere to min set back requirement❑
or Commercial Installations:
Replace same w ig ❑ Additional weight (structural calcs) ❑
St ural Calculations req 'red for new installation ❑
N installation Planning A rov 1 Required ❑
st of Project: Type o Construction: Occupancy group:�
0
St ped On Platf ❑ Bonded L: - Sq.Ft. Fly Area:
New Location Replacement
❑
Qty. if
Appliclf, Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfrn 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
J BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING