04020104 CITY OF CUPER'I'INO ,* . s' r 't�s �
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .d
'+ 3"'%$3.x �,•• fE12J4
BUILDING ADDRESS: CONTROLLED SYSTEMS OF CALI PERMITNcb4020104
OWNER'S NAME: PERMIT ISSUE DATE
QQA
ONE: SANITARY N'0 CONTROL N0.
ARCHITECIYENGINEER: BUILDING PERMIT INTO
BLDG ELECT _ PLUM MECH
Lo'z LICENSED CONTRACTOR'S DECLARATION
y U C 1 Mmby vffirm Nm 1 am licensed undo pmvivom of Chapter 9(commencing = Job Description
� U with Section 7")of Division 3 of NC Business,aM professions Code.and my license is
j�e, , in full fares andef[ML Ann A/C APR U 2 2004
_ License Class L L'e.a j8f �—
nt- Dam Z Ill < Comn'm
ARCHITECT'S DELLA ATION
I undcreund my Pla shall hlie=orm BUILDING
30G Licensed Professional
3 OW ER UIIDERDECLARATION
.�<y I hereby affirm that a exempt foo the Contractor's License Law for the
O O following moon.(Section 7031.5,Business and Professions Cods:Any city or county
$ which requires a permit to construct.alter,improve,demolish,or repair any someone
FI< prior m its lssmna0,ld.Rqui.theapplicaut for such permitto EleatignedalaNment
dual he Ls licensed pursuant to the provisionsor the Contractor's License Law(Chappell 9 Sq. Ft. Floor Area Valuadoii
(commencing with Sccuon 70DO)of Division 3 of the Business and Prufesnom Coda)or
y w 3 Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3 ��0 Occupancy Type
not mom Nan five handled dollars($500).
❑1,as owner of the property.or my employees with wages as their sole compensation,
will do the work.and the swaure is not intended m offered for sMe(Sec.7044,Bourton Required Inspections
and Professions Code:The ConbvcLt.ls Lilaw dam nne
ot apply o sr owr of q P
pmpeny who builds orharpooner the,mo.,and who doessuch work himself or though his
own employees,provided Nat such impmwmens arc not intended or offered for sale.It,
hawowl,the building or improvement is sold within one year of completion.Ne owner-
builder will have the burden of proving Nat he did not build or improve for purymc of
sale L
❑I.as comer of the proven.am eadusively contracting with licensed rontracon to
consumer IW pmjea(Sec.1044.Business and Profcadrm Code:)The Consomme&U.
case Law docs not apply m an owner of pmpcny who Wilds or improves themon.add
who contracts for such pmjces with o cammatortq licensed pursuant in Ne Convector's
License Law.
❑I am exempt unser See .B k•P�er ch on
137CM
ner Dam Z
W ER'S COMPENSATION DECLARATION
1 beach y eRi under penalty of perjury oT of the following Oscillations:
1 haw and will maintain a CeniGwm of Consent to self-insure for Worker's Compen-
on,as provided for by Section 31W of the LaWr Cade,for Be Performance of the
rk for which Nis permit is issued.
1 haw and will maintain Worker's ComNmauon Insurance,m required by Section
of Nc rubor Code,for Nc performance of the work for which this permit is issued.
y Worker's Compensation Insurance carier and Policy number artrtier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seeds need nor W completed if the permit is fora¢hundmddoll.(SI W)
or less.)
I certify that in One performance of the work for which this Permit u issued,I shall not
employ any personany m ncm be
r an as coo me subject de Workcri Compensation
Laws of Califomia!D.
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the 4 Wr Core,you..at
.�Z forthwith comply with such provisions or this Permit shall W deemed revoked.
zOCONSTRUCTION LENDING AGENCY
IWmby aRrm Nan Nem is a construction lending agency,for the performance of '
C
On walk for which this permit is issued(Sec.3091,Civ.C.)
W p Leader's Name
z Lender's Address
U O 1 certify Nu I have mad this application and We Nat the,vWw unromantic.is
W f"
correct.I ages to comply with all city add county oNiaanas and sum laws relating to
O U Wilding construction,and hereby authodm mpexamuiacs of this city to enter upon the
r W above-mentioned property for imKcuon purposes.
(Wo)agree to save,indemnify and keep harmless the the City of Cupertino against
„F. Tn'A liabilities,judgment,costs and expenses which may in any way lame against said City
U in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ��
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
signawre of Apvli<aDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the aapplicantCured a future building e.Chapter
sono oranndlc Heanious lth and
as Ocfinee by Bur Cupertino Municipal Code.Cnapmr 9.12,and the Health and Safety
otic,ElY.235]2(x)? No All roofs shall be inspected prior to any roofing material being installed.
,Will the app icant or umm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nit ar4rdnus air<onumldans u dcfncd by Ibe Bay Arca Air Quality Managcons, all new materials for inspection.
Dlslrlfl? ./
O Yes I'j N.\
I have read Ne h.rodons�materiais da,imme.ts under Chapter 6.95 of the Califon"
nil Health k Safely Ccdc.Sections 25505.25533.125114,I understantl Nm if lW Wilding
des not cunemly haw a¢hent.Nm it ix y resrysmihilily m oddly the occupant Of Nc
regnimments when most W poor smanee of i certificate of OccuPaney. Signature of Applicant Date
Z i3 c
Owner oranth.rimdagent Date All roof coverings to be Class"B"or better
Community Development
' atM
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
/ ! Suildin De artment
JOB ADDRESS: co l PERMIT #o � O,,�-o r 0 `t
OWNER'S NAME: z I S-LLLCL nn %s PHONE # S0/ 9'64—
GENERAL
SD 6 —GENERAL CONTRACTOR: Co A, r o H c S-( #
I am not using any subcontractors: Z /3
S ature D to
Please check applicable subcontractors and compo ete the follownformation:
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
10/28/03
CITY OF CUPERTINO
FURNACE/AC
UPERTINO PERMIT APPLICATION FO
Nor APN # 3S� (,& O Z S Date: /
D
Building Address: 2 Al
Owner's Name: r, 1 Phone #:
Contractor: I / S s1rMS Phone: 6SO 96V 3� License #:C ZD
C0�1tro�lt ST33
Contact: Phone: Cupertino Business License#:
/✓`IRC. L2 �,4t rv.v� .
Building Permit Info:
Bldg D--' Elect ❑'- Plumb Q'� Mech 0�
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor❑
Adhere to min setback requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
q 7 S O
Strapped Ll On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable 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
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
lisPPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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