04090010 CITY OF CUPERTINO `�< + 't'
BUILDING DIVISION PERMIT �sCONTRACTf)RINF,ORMATION�:
BUILDING ADDRESS: SUPREME AIR SYSTEMS PERMITND04090010
SPORT T)p
OWNER'S NAME: PBRMITISSUEDATE
MICHAEL FRAN
ONE: SANITARY NO. CONTROL NO.
(408) 376-0406
ARCHI
08 376-
ARCHITECT GINEER: BUILDING PERMIT INFO
BLDG Ef.ECT PLUMB MECH
0 0 0 0
=oo LICENSED CONTRACTOR'S DF.CLARATION
I hereby aforn that I am It it undo er . ., pr sions of Chapmr 9(commencing Job Description
I.
with
I IXMs)r'fDiviaion3
Ed of Nc Bust"^<. f t my],,an.is
R PLACE FURNACE
in mand
S iAZ Liccn o s Lic.N _
�r� Dam Convaclor r t{
pp A� Call he D6CLA ON i C, I undcraunJrtri plans shall M=it as public records
JyU L
3 a0 Licensed Pnsfcssional
S
OWNER-OUaexempt
DEC.Curat ON
3 i S I herchy.(Oro that I I.S.escmpt from the Cssions o License Law for the
p O following rcuoa Permian R13 LBusiness dna improve.
da i oli Code:Any city s county
x m which requires a purest to cnruwct,alcor,improve.dcmolLsh,or repair any suucwre $1 tznn
v prim to its issuance.also requires the applicant for such permit m File a signed statement
that he is licensed pursuant o the provisions Of the CammmmrS License Law(Chapter 9 Sq.Ft. Floor Area Valuation
n (commencing with section 7000)of Division 3 of the Business and Professions Code)or
that Is,is exempt therefrom and the basis for the aluged ommption.Any violation of
Schon 7031.5 by arty applicant far a permit subjects N,applicanfm a civil penalty of 3 56)N1M1uhA:er0 0 Occupancy Type
not mom than five hundred dollars ISM).
❑I,uownuoflhepmpeny,ormyemployceswiNwegesm Jmirmiccompensation,
will do the wort,and the he Com is not i Lacer or a w does
an,apply. an
Business
and erafesuom Code:The Conuureh and who ma,does not apply lf an owner is Required Inspections
property enywyees,provided
Improvements
andwho aaeast Inch tended
aroffe n!Ihroughformle his
me employees,ping or improvement
Natovenimpmvemcnuatanot;ended pleum.Elleowner-
builder me building or improv ementissoldwithinone year of completion,theose of
builder will have Ne burden of proving Nat the did not Wild or improve for purpose of
We.).
1,as owner of Na property,am exclusively contracting with licensed commo ebR to
convert Jae pmject(sec.7044.Business and Professions Code:)The Comnemh Li-
ens,Law does not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a conmcmr(s)licensed pursuant to the Contractors
License law.
❑1 am exempt under Sec. .B&P C for on.reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hemby ahem under penalty of perjury mm of the fallowing deck atimm
I have and will maintain a Certificate of Consent to self-insumfor Worker's Compcn-
unam.m provided for by Station 371111 of Jm Labor Code,for Ne peofurrnance of Ne
work for which this permit is issued.
n 1 have and will maiden Wmloc,.Comp,nvuon Inmr .,as requited by Section
3700 of Na lahor Cede,for the pedormanee of the rk for which this amtit is issued.
My om0engauoa a acs liry 0umbrr m: QZ
Ca 1.... `` Policy No.: W a� z cilk
CERTIFICATE F EXEMPTION FROMW0RKERS'
COMPENSATION INSURANCE
(TItexce,don need not becomplemd tribe lamest is for one hundred dollars(SIM)
nr kR.)
I certify that in the performarce of me work for which this permit is issued,1 shall not
employ any person in any manner se,as w become subject to the Worked Compensation
Lewis of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
became subject m the Worker's Cbmpenution provisions of the Labor Code,you min
.,O faMwith comply with such previ¢imw Nis is permit Nall be deemed mwkcd.
z CONSTRUCTION LENDING AGENCY
E-, l hereby affirm that Nem is a convection lending agency lot me Performance of
a 7 the work for which this permit u issued(Sec.3097,Civ.C.)
Cgd A Lendar's Name
= z lender's Address
U C I certify that 1 have read this application and sum that the above information is
(L E. corms.l agree to comply with all city and county ordinances and sum laws mining to
0U building construction,and hereby authorim repmrtmatiws of this city to cmcr upon Inc
shave-manu boo propert 4 Purposes.
H 4. (We)ag ,indemnify an Ince,hrm
alessthe City of Cupertino against
N limithics.ju cru, capcncs ich may in any way a<cruc against said City J
V z Acon cc of the
APP UNTIE TND ArN� ILL COMPLY WITH A L NON1�POINT Issued by: Date
e J`
Re-roofs
g ire rya n bur OUS MATERIALS DISCLOSU E Date Type of Roof
Will Inc apPb< r on building uccupam nam or handle hmallous mamuil
az defined by the Cut umm 1 Code.Chapter 9.11,and the Hann and Safety
Code
El es 1s531(a)T All roofs shall be inspected prior to any roofing material being installed.
El yes No
Will the applicant or future building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
.mit hvmdnus air can. defined by the Bay Area Air Quality Management all new materials for inspection.
DisvinT
❑Y No
1 woad the
I sin rialsmquimmcnuunt rChapmr6.95ofthc Califar
ni H 3f1S.26533 wJ 15534.IuMcrsund thaziflM Wilding
J responsibility b motif occupant of c
r nimm nm ,normissaan gram a�a Signature of Applicant Dale
Ow, r mt Orr<Jase Daly All roof coverings to be Class "B"or better
.„,.� Community Development
c 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESSIO PERMIT #
A
OWNER'S NAME: C PHONE # -
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
ture Date
Please check applicable subcontractors and corn ete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
O 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 Signature Date
CITY OF CUPERTINO
FURNACE/AC J st' l o
' CUPEI�fiNO PERMIT APPLICATION FORM
APN # C� 1 I 0 J Date:
Building Address: 1
I�
Owner's Name: Pho #: �7t�
O �n - 1 7 v
Contractor: r , ^CFt.S Lice .
Contact: Y� Cupertino Business License #:
e-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Z:)
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor2"`t floor ❑
Adhere tc min set b ck requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
Nexy installation Plannigly A
ypproval Required
P rcrieect . / Type of Con ru - Occupancy gro
on: p
Strapped LJ On Platform U B Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if.
AppliqqbI 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 Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business LicenBUILDING
se
IJ
v
2