05060021 CITY OF CUPERTINO +'
BUILDING DIVISION PERMIT C0' NTRACT0R.M,ORMATIUN `'
"-91LDING ADDRESS: A PERFECT CLIMATE PERMIT"°05060021
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(408) 861 -954c;
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0 0 0
glop LICENSED CONTRACTOR'S DECLARATION f��fJob D'es�"ription
r��+ I thereby affirm that 1 am liccmed under provisions of Chapter 9(commencing (t 1
with Section 7080)of Division 3 of the Business and Professions Code,aha my licewis '�n�
(n full farce an0_ / V
5 Lken Clw of Lk.♦ 3 I ADD A C
Dau: Cantradar
ARCHITECTS DECLARATI
a 1 understand my plans dull be haul As public mcnrds 1f1 IIJJ(u�:.1J
3600
laud
Licensed Pro(cuiond
OWNER-BUILDER DECLARATION
I I hereby oRrrtt that I am exempt from the ConvectaYs License Law for the O
C O following mason.(Sudan 703 1.5,Business and Profossiom Cade:Any city or county
u�3 which requirm s permit to construct.alter,improve.demolish.m repair my structure
tZ�m prior or its issuance.also acquirers the applicant for such permit m Bic a signed statement
FF that he is licensed pcommit in the pmvlate.of the ContractohlJamcLaw(Chapter 9 Sq.Ft. Floor Area Valuation
e(�$ (commencing with Section 70W)of Division 3 Cftha Business and Profeolan Code)or -
'�
that k 4 exempt themfrom and the basis far the alleged exemption.My vlolaUun of
SoOm 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 t*er0 0 Occupancy Type
trot more than five hundred dollars($5007.
❑Las owner of tha property,u my employees with wags as the4sola umpewUon,
will do thewoh andthe structure is notimended Proffered fomak(Sm.7044,Busitaa Required Inspections
and Profession ms
Cade:The Caactnr' dam s License Law ant apply to an owee nsr of q p
property who builds orimproves thereon,and whodomauch work himselfmthrough his
own employcos,provided Nat such improvements arc notlmanded oraffered fossale.If.
however.the building or improvement Is sold within ata year Of completion,the owner.
Wilder will have the border of proving dol W did not build or improve for purpose of
mile.).
❑I,as Owner of the property,am exclusively contracting wish licensed crommu rs in
construct the project(Sec.7004,Business and Professions Code:)The Contrecmr'a U.
cense Law duo not apply to an Osman of property who Wilde or improves Merton,and
who contracta for such pmjeeu with aeantrclor(q licensed puraumt to the Contractor's
Lkenm Lew. 1
0 1 em exempt under Sec. ,B&P C for this mason )
Owner Data
AL WORKERS COMPENSATION DECLARATION
1 hereby ism under penalty of perjury one of the following decimations:
IM.and will meintsin a CwtiOcate of Cavum reset(-insure fos WarkehCampcn-
sation,As Provided for by Section 37M of da labor Code.for the performance of the -
we*for which this permit is ismad.
I have and will maintain WorkeYs Compensation Insurance.as required by Section '
67110 of Ne Leber Cold,far the peRormsnu of the work for which this permit is issued.
My Workeet CampewliOn Im mance carrier and Policy number am-
Carrier.:4LarlYl�kl Policy NO.: L
CERTIPICATE OF EKEMMON FROM WO ERS'
COMPENSATION INSURANCE
(lh section Cecil not hccomplead if ted permit Isforonehundrtddo0w(SIM) ,
or ICU.)
I unify that in the performance of the wadi for which this pewit 4lssued,l shall not
employ any person in my owner an As in become subject in the Worked Compensation
Laws of California.Dam
Applicant '
NOTICE TO APPLICANT:If.after making this Ccnificate of Esemption,you should
became subject in the Worker's Compensation provisions of the Libor Cold,you mum
.J z fOMwith comply with such provision Of this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
[.► I herchy affirm that Vert isacmohucdnn hndinggenoy fm Ua crfurmanceof
ai
the woh for which Nis permit 4 issued(Sec.3097,Civ.C.)
W�Q tender's Nunn
z lender's Address
U0 1 certify that 1 have mad this application and mute that Ne above information Is '
W correu I agree to comply with all city and county onlises aha sera laws rem
lating
(7 Wilding construction,and herthyauNorim reprexnudves of this City to enter upon the
W above-mentioned Property for Wpctian Purposes
l�..v.gy (We)agree le on.indemnify and keep Wireless she City of Cupertino gmnsa
it f/y, Iiabilides,judgments,cmu and expamer,which may in any way seemed against said City
V~rj-r In consequence of the growing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OU c
SW 9, k- ,q/ra (49 a -0
Re-roofs
Signature of ApplicmuCoData
HAZARDOUS MATERIALS DISCLOSURE 'Type Of ROOF
Willy t applicant a(muse building Co e.Chapter
atom arhaMk h eaNam material
as dc0ucd by da Cupertino Municipal Cade.Chapter 9.11,and Ute Health and Safely
ode.Seedon 1553:(.)7 1X
All roofs shall be inspected prior to any roofing material being installed.
❑Yos ,hp,Na
IWill da applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
li havardam air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
D4miel7
❑Yca
Ihewrcadthehvadnu mwrialsmquimmen4undcr Chapmr6.95ofthe Califor-
nim HeslN&SafnyCode,Scniau7SN75,25533md25534.Iundc.na ifda Wilding
does not certainly have•tenant,thw It 4 my rcapomihll y to notify the occupant of the
req menu which most W et pier issuance f a ficate of Occupant
'kaly � � Z 0 �- Signature of Applicant Date
Owner orauthad,ed.ent Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
b� Cupertino CA 95014
Telephone(408)777-3228
C OF Fax(408)777-3333
�UPERTINO
Building Department
JOB AD KESS: PERMIT#
6cr2/
WNEWS NAME: PHONE #
GENERAL CONTRACTO FAX #
I am not using any subcontractors: d
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 Signature Date
Nil
CITY OF CUPERTINO v o a z
FURNACE/AC vS
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Yo &- -o �5-
Building Adf�ress:
00
Owner's N e: Phone#:
C
tr tot: License#:
'102 C5/ S
Contact: _ Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
,fid )49 up"
Residential Commercial ❑
For Residential Installations:
Attic ElI" floor 2"d 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 Approval Required ❑
Cost of Project:: 2 Type of Construction: Occupancy group:
Strapped ❑ On Platform LJ Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMARUTAN 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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