03120047 (CITY OF CUPERTINO
BUILDING DIVISION PERAIITC+ N`P ' ��.�A' I _,,:.
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NOb3120047s
OWNER'S NAME: PERMIT ISSUE DATE
B
NE: SANITARY tftOl.NO.
7ARCHTIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 licmb„form that 1 sus IkxnsW under pmvldon of Chapter 9(commcMng /*� Job Description
s.d.7mk1 of Dlvhion3of the Busfnw.dPmfeasm.Ca.andmylicensulsn5 PLACE FUR ACE
zDnt I tee.{�fL
3 Date Con DEC
ARCHITECTS use DECLARAnON
licm.m
I undersand my phos shall M used u public meords
jLicensed Professional
N OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from Ne Cantrown rs License Law rat the
' p o following mason.(Section 7001.5,Bumm ns and Profusion Cade:Any city at County ((//
$fLi which notion a permit to Convect,alter.Window.demolish.M ACPoif soy urecture
prior to its Issuance.also requires Ne applicant for such Permit to Neo signed statement
FFC
that he is licensed personal In the provigomafthc Contractor's U..Law(Chafing Sq.Ft. Floor Area va tool
S8 (commencing with Section 700y)of Division 3 of the Business and Professions Cude)or
is
that he Attempt r”-�fmm and race basis for the alleged namption.Any violation of -
Section 7071.5 by Any applicant for a permit subjects the mom N 55001. applicant m a civil penalty of 3 p1 Ig�erp p Occup pe
not an nve hundred dollars(
❑1,As ownu of the properly,or my employers with wages As their sale compensation,
will Pr timework ands: he Continuities
Lica a Law itdf An,a(Sec.7041.Buaonss
and Profession Code:The C smorcon,Llama Law dote ret apply l(in owner of Required Inspections
own
property who Wilds donsucAremalma nkhMu3fmNmu{hhla
own employees,provided or Improvements Nat such Impmvem.0 tee.Uear dedole m oRered for tele r..
Wilderhowever,the building m eg sold a did as year of completion,the aw.r-
builderwill haw de bunco of paving Nat h did trot build or improve for purpose of
tele.).
I.u mover of the property,am ucludvaly Contracting with licensed contractors in
convect the pmject(Sec 70M.Business and Profession Code)The Contractors U.
one Lew dao not apply to an owner of property who builds or imp..them.,mad,
who contracts for such pmjecu with s.ntracrtr(s)licensed pursuant to the Contractor's
Lice.few,
❑I Am uempt under Sec, ,8 R P C for this ran.
ow.r Dam
WORKERS COMPENSATION DECLARATION
1 hereby of irse under penalty of perjury am of the fallowing declaration:
I have and will maintain a Certificate of Consent m¢lf-inure for WohefsCompen-
sation,u provided far by Sectlan 3700 of Ne LAW,Cade,for No perform An.of Ne
or which this Permit Is asum.
1 have and will maim.Worker's Compensation Imuran,As required by Section
W of the labor Code,in Ne perlarmantt of tie work far which this permit a luuad,
M Workch W
Com enon Insu n cAMcr and Polity n
C'Me, t Iry No.:
CERTIFICATE OF ( ON FROM W KERS'
COMPENSAT&k INSURANCE
(This section rad not ad e remitted If the Permit is o.hundred ohundred dollua(S 1W)
,it last.)
1 unify that in the performance of tiro work for which this permit is Caused,I shall nth
employ any person in any manner an As to Mame subject to Ne Wofteri Compensation
Laws of CAllfomia.Date
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Eaomption,you should
become subject to the Worker's Compensdon provisions of Oe labor Code.you mute
Z forthwith comply with such provision in this permit shall be decmad revolted.
.Z.t O CONSTRUCTION LENDING AGENCY
[. 1 hereby affirm that dirt is.comtrucWn leading age.y rot the performers ser
a> the work for which this permit Is issued(Sec.3097,Civ.C.)
dQ Lender's Nuns
Z)z Leodeh Address
I)O 1 cemfy that I haw read this application.d sum that the above information Is
w;'! comma I agree to comply with all city And county ondire n,and state law mining to
0 SV' building construction,and hemby suNariae mprawmatisq or this city in enter upon Ne.
W above-mention0 pmpeny for impecd.purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
,A liabilities,Filgmcros.eosuand expense which may in Any way same against Aid City
U 7 in conseq.nce of the granting of this permit
•^� APPLICA NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R LA N5,
Re-roofs
fAp or
HAZARDOUS MATERIALS DISCLOSURE 0 Type of Roof
applicant or furore building occupant mora or lundle Initiation material
u dcri.d by di Cupertino Municipal Lode.Chapter 9.12,'nd the Health and Safety
Come,Section n531(a)7 Llilding
All roofs shall be inspected prior to any roofing material being installed.
❑Y.Will the applicant art «.pant sac equipment ser dc.iast which If a roof is installed without firstobtaining an inspection,I agree to remove
mit haardn.air.numinnf by Np Bay Am Air Quality Mangcment all new materials for inspection.
Distrin7
❑Yes
I have mal the husm.s mamriaLsoximmmenta underChapmr&95of&Cal ler.
nh HalaBSafcty Cadc,Scctiom15505,35533md25534.Iutmrntsndmatif Ne.building
does.t cuncntly have.tent Nu It ts my rest anibility m.dry Oi ocnpsnt of the
mquimmenu - mute et priorw tsso.a oraC.inasm ser Signature of Applicant Date
owner must '.doge Da All roof coverings to be Class"B"or better
CITY OF CUPERTINO
y�(G. FURNACE/AC
CUPS OF
PERMIT APPLICATION tZ C ON FORM
APN # 3 Z 03 Date: 0�
Buiding ddress:S
m
. S
Ow is NamOSQ e:G 1 hffiRoja hone 1�
C ntrac[or: Ph e6 22� -q5` f ensu
onta r c Phone: i � upertino Business License #:
Building Permit Info:
Bldg ❑ Elect) 7 Plumb ❑ Mech
Job Description: Qep(u(e -LA(y\G(
Residential Commercial ❑
For Re idential Ingn�allations:
Attic LJ I" 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 ❑
Costof ro'ect: ,�� Type ptf Construction: Occupancy group:
Strapped LJ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
App c le 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 Lic se BUILDING