03120064 ! CITY OF CUPERTINO ' :'.
BUILDING DIVISION PERMIT CONTRAEQR TNTtMA.Txd111s .:
BUILDING ADDRESS: A rPERFECT CLIMATE FERMITNOb3120064
OWNER'S NAME: PERMIT ISSUE DATE
STEWART
NE: SANITARY ftkOL NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION JbDescription
UW M
I mby affirm that 1 am IicciuN ns under provision of Chaptero
9(commencing
wim Sectfon7W of DivWo ofNCBusinwand Profeuium Code, my consul.
nE m full fm:e and tt
Z"
rs� License Cl LIwN �2- S EPLACE FURNACE & ADD A/C' -
Z F,p Dau Contras
q CHITECTS DTION
a
[understand y plans mall be med u public reeoms I�D
3�tn Liceved Protests onal FINS
01 OWNER-BUILDER DECLARATION
mI homey affirm mat 1 am ucmpt from the Conductor's License law for the g3 [ rSQQst
zoo following reason.(Section 7113 1.5,Business and Profession Code:Any city or county 1 pN 2 J L Y
$� which requires u Permit to mmwCl slur,minnow,demolish,or repair any structure J
riy prior to its issuance.alto requires the applicant far such permit be rile a signed statement
mat ho la liccued pursuant to me pmvislOM of the cmulemfa U..Law(Chapter 9 Sq.Ft. Floor Area BU�i (�(tn�
u (commcming with SmOon]pp)of Division]of me Businm and Profeuiov Code)ur Lu �Y�
$
that he u exempt therefrom and the basis for the alleged muception.Any violation of
Section 70315 by my,applicant for•perm,subjects tins appllunt In a rivil Penalty of 3 6�N 4N 0 Occupancy�'Pe
not more Nm Bw hundred dollars(ML
❑L as owmrle sod propmy or my cmployce with wage u men rule e0mpeoatmus
will Professions
r ldohesions.end me he Comb not Intended m Law
do s not apply
a4,owner
of
aro Prtywh obu Code:The Canuumn,License law dao or apply lf an owner of Required Inspections
own
property who e s,pro vidd Oat m thcrmn,and who does ouch work himael f or mmu{e bla
ownemployee,lding orri thatsuchimpmwm wt arenot yea ofe mpletied foe tale IL
bowewA me Wilding car impmwmmW mid within one yeti of cempledon.the comer,
builder will haw the burden of proving Wt be did not Wild Or imppurposew far purpose of
.t
tile].
❑I,u owner of dm property,am aclusively contracting with liaved contractors m
construct the project(Sec.7044,Business add Profound.Code:)The Contractor's U.
cove low docs not apply to an owner of property who WBds or imp mews theme.and
whoemerso ts for such projects with s contractor(.)licensed pursuant m the Cwtraemr'a
License Law.
❑l am exempt under Sec .B A P C for this moon
owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under mrta,y of perjury am of to following decimations:
1 have and will maintain aCcelfem,of Consent 10selRlvum for Worker'sCompen-
sation,as provided for by Section 3]00 of the labor Code.for me performadm of the
a for which this permit is issued.
Mw and will maintain Worker's Compensation insurance.as required by Section
T fthe labor Code,for du performance of the work for which this permit is issued.
My Worker' C rope sation Imo me carticr anup altry re r
Cartier. Policy No.:
CERU ATE OF EX ONFROMWORKERS'
COMPENSA INSURANCE
(Thissection need not he completed if the Permit is for one hundred dollars($101))
or Ica)
I cenify mat in the performance of the work for which Nis Permit is issued,I shall not
employ any person in any manner m u to become subject o the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after mining this Ccnincam of Exemption,you should
become subject m the Worker's Compevntim previsions of the Latour Code,you must
�Z forthwith comply with such prssvol or this Permit shall be deemed rewsed.
.�iOCONSTRUCTION LENDING AGENCY
[—r rte.. IMmm th
by affirm mem is a commuctlon lending agency for mm e perfurmanof
!Yi
On work for which this permit is iumd(Sec.3W7.Civ.C.)
W Q Lendce.Name
z lender's Address
U O 1 certify mu 1 Mw sea is app'anon and sum that the show information u
W F conecL 1 Agan m comply wi all my d county ordinamm end state laws relating to
V Wildingconstsuction,and mbya orixmpmxwalwoofmisedymenteruponmc � —/,/////
W abavomen6unrd prone tori don purposes. V"^�/a4[Jw/ 4 16
0. (We)agree to i sonify and soon harmless the City of Cupertino against
H in
f u dexpe hich may in any wyaccrue agunst mid City
(„)z in consequence of canting of ' perm . LL
'" AP ANT U RSTAN AND WIL COMPLY WI AL NONNO fT' Issued by: Date
S RCE R ATION 2 YY//
' Re-roofs
Sipsom, Applic ontracmr Date
HAZARDOUS MATERIALS DISCLOSUR I Type Of ROOF
Ilse pp liamorfotumWldinguec otsbom orharrdlchmndousmamrid
u d o' the Cupertino Munic' el Code.Chapter 9.12,and the Health and Safety
Id
ade.Section 255320)? All roofs shall be inspected prior to any roofing material being installed.
Ya o
W.11 the appfiaant-'rum
WI g occupant a equipment car devices whish If a roof is installed without first obtaining an inspection,I agree to remove
mit haaNnv air contaminants fined by dm Bay Area Air Quality Management all new materials for inspection.
❑Yes
I haw madthehavasd usmamrialsmquimmenuunderChapw6.93ofineCalifor-
laHcalth6Safmyfodc,S bu25505.255JJ uW2553d1unlrstaM Nmifine Wilding
os retcomwmyrepy�tsihilityedmdfy oaupamoftheqa( wan t oder armiasaangobya tratyyrod nry. Signature of Applicant Date
owner car as ariade I[ / oath All roof coverings to be Class"B"or better
CITY OF CUPERTINO
��v- FURNACE/AC 3/ Zai �
CUPEkTINO PERMIT APPLICATION FORM
APN # ' Date:
Building Address: !\n^^
XT Ca2
(�1 ► 't 1 h yew#:
V 2
Co tractor. Phone: / / License
Conta � Phone: 1 Cupertino Business License #:
Building Permit Info:
Bid. ❑ Elect Plumb ❑ Mech
Job Description: (c�o—o— & ti -A :N�
Residential Commercial ❑
For Residential Ins allations:
Attic 111S`floor LJ 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 A2proval Reguired ❑
Cost of P oject: Type of o si�ucr. n: ccupancy g up:
Strapped LJ On Platform ❑ Bonded El Sq.Ft. loor Areq�
New Location ❑ Replacement ❑
Qty. if
A li e 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
:ZIP: BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Pernut Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING