04050055 CITY OF CUPERTINOGta''rr�` i t�,-`�. .I �j, M� ®�I. ^,
BUILDING DIVISION PERMIT , s �
BUILDING ADDRESS: A• PERFECT CLIMATE PERMIT N004050055
"I fi4e MOMR017TA RT
OWNER'S NAME: PERMIT ISSUE DATE
SITYAM TAVO SANITARY NO. CONTROL NO.
ONE:
408 861-954
ARCHDEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
M0 z' LICENSED CONTRACTOR'S DECLARATION
< j hereby affirm ft,1 am licensed under previsions of Chapter 9(commencing IP UO
< with Section 70110)of Division 3 of the Business and� i nnsss Ct and my license is
a, infullforceond e JVQ REPLACE FURNACE & ADD ASC
b
ME License Clun LIC.g
a Dere CUnlrecmr
ARCHITECTS OECLA 1 N �n NOV a q 2004
�CC� IundcrsoonJm pl��el�_gtln Pu mcnNs t^-'�(I rlG/
DaV
o C Licensed Prefcy affix BUILDING U I L D I p it�\
g OWNER-BUILDER LARATION yK '\V,/VY_
0 I menu .(firm that I on
exempt from the Contractor's r'a License taw for the
DO followingmason.permit
](131.5,Business and Professions Code:Any city structure County
x m which requires a permit to porter ft pion improve,demolish,or repair any tWment
riy Pdormits issuance,edpursarequire thovisioso for mchPermit loicensle asigned annmenl
pp
that hmenci gwJpSectiol70th)ofDivionsn othe f IM
Contractor's ndPrselaw(Cho Code)
Sq.FL Floor Area Valuation
r4 dust he is
(commencing Section and the
basis
3 the al eged assumption.
on.Any
Gxle)of
y�� that he u eumpt therefrom and dte buts for the alleged cumptlon.Any violation of
Semon 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3 5+ N31Ii1r&cr0 0 Occupancy e
not mm than five hundred dollars(5500). P Y ')p
❑I,as owner ofdmproperty,or my)mployced with wages u their selecompensatlon,
will do thework.and theawcture is alinnnded oroaered foraale(Sec.7044,Busimeas Required Inspections
and Professions docs Out Cade:The Cmdowi 's Lica se Law donot apply n an owner of q p
Property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements art not mounted trr dflared for sale.It.
however,no building or improvement is sold within one year of mmpledon,the Owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1.u owner of the property,am exclusively contracting with licensed contrmnrs to
construct the project(Sec.7014,Busincei and Professions Cade:)The Conmacmr's Li.
cove law does not apply to an owner of progeny who builds or Improv thereon,and
who contracts for such projects with a amnnor(s)licensed pursuant to the Contractor's
License Law.
El lamexempittolm Sec. ,B&PCImthisteuon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have end will maintain a Ccnificate of 0memato wit-insure for Worimes Compen- `
sedan,u provided for by Section 37W of the labor Code,far the perform. ..ncf the
work for which this Permit is issued.
❑1 ham and will maintain Workcri Compensation Insurance,u required by Section
3]W of the labor Code,for the performance of the work for which this permit is issued.
MyWorker's am Ins.to.lnsomum ammb
immul Policy cr are:
Ceniee
CE •CATS OF EK PTIN FRO WOM RKERS'
COMPENSA ON INSURANCE
fTMs action mod not he completed lithe Permit!,form=hundred doll am(SIM)
or less.)
1 Certify Not in the performance of fee work for which this permit is issued.I shall not
employ any person in any manneru as to immure subject to the Worker!Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you shoultl
become subject to the Worknes Compensation previsions of the labor Cattle.you must
.JO forthwith comply with such provisions or this permit shall be deemcd mvokcd.
Z iCONSTRUCTION LENDING AGENCY
[r I hereby)Rum that there is a constructinn lending agenry for the Performance of
ai th)work for which this permit Is issad(Sa.309T,Civ.C.)
aQ Undoess Name
z Lender'ees Address
V Q I modify that 1 have mad this application and soon that the ahem information is
II.f~ correct,I agree to Comply with all city and county ordinances and state laws relating n
QU building construction.and hereby authmias representatives of this city to ente"pron the
W above-mentioned property for inspection purposes.
(We)agree to sate,indemnify and kap intends.Ne City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acerae against said City
(.1 z in consequence of the Starting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS, ,,.
Re-roofs
Signature ofApplicmUConData
n
US MATERIALS DISCLOSURE Type of Roof
Will the a Cupertino
or future building acupant atom or handle Hearo0us material
u defined by the Cupertino Municipa apmr 9.11,and the Health and Safety
Al&mlo.Semen 35531(¢)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant or future buildin rt use egaipmat or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardnus air c0noominents u do y the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes No
I ham mad the huardnusmaterialsmquimmcnts unerdChapW 6.95 of the Califor-
niaHealth&Sarclycode,Sesmas 15505,15533 534.I understand thatifths building
Joos not currently hoc a so m,Naz it is an sp edibility to notify the anor.m of the %
mgfi.o men tsw hmus"me its of a Ccmfican of OccuhmC -/(j��lof Applicant Date
on er amhonaotl age an V-o..^'-/'r All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
t,. Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building Department
JOB ES'(Y�� PERMIT #
OWNER'S NAME: Y' -f �vywj PHONE a
GENERAL CONTRACTOR: FAX # (9 1
I am not using any subcontractors: O-Ye�a
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 gignz Date
CITY OF 'CUPERTINOZT,
ILCEJAC _
CUPERTINO PERMIT APPLICATION FORM
AP36 61930 1 G Date:
O �- lolo�-1
Building Address:
2rl s 4�p 1MC7�1 lav i c� S�
Owner's Nanit`_ �� ,a��� Pon #: 2-090
2
Cont ct r: 1 �, Phone: ! ry I nI S l I,license #: 231 S$
Contact Phonewyvj s �V� �j L4, � Y Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Job Description: eeqy-�� n ,,,v,-Lacp cAy-L(.A A--I G
Residential ❑ Commercial ❑
For Residential Installations:
Attic ❑ 1 s` floor ❑ 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement sante weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Required ❑
Cost ckf Pro'ect: / Type pf Construction: Occupancy group:
Strapped LJ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
if
A ica e Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
13REMFURN 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
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee YA BUILDING
BUSLIC Business Licens Z BUILDING