04120145 •CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: A PERFECT CLIMATE Picy ND04120145
NER'S NAME: PERMIT ISSUE DATE
OW
MICHAEL FUN
ONE: SANITARY O. NTROL NO.
408
ARCHITECTFENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONRACTOWSDECLARATION JbDescri Description
-
YsF 1 hereby affirm Nat I am licensed under provisions of ChapteroP
9(commencing
<Zy widr Section 7")of Division 3 of lbe Business and Professions Code.and my license is
j�?<a imm�mmeanamt`t FURNACE/WATER HEATER REPLACEMENT
Llcensc Class Lic.g
Z�l Dale Contractor
ARCHITECTS DECLARATION
�i,2I understand my plans shall W used as public records
Dy
.'�G y
Licensed Psfcssiorul
3 OWNER-BUILDER DECLARATION
1 hereby norms That 1 am exempt Iwo the Committees License Law for the
O C following rases.(Section 7031.5.Business and Profession Code:Any city Or county
which requires a permit to conarucL Filter,improve,demolish.or repair any suuctund
Tai prior to its Womice.also require tM applicamfor such Permit to filo asigned sttomemt _
G Natheisliansed pursuantmNepmvisiomofine Contscrors Lianas law(Ch,,W,9 Sq. Ft. Floor Area Valua[on
(commencing with Section 7")of Division 3 Of LM Business and Profcasions Code)or 7
y $ that he is examen Werefmm and the basis for the alleged exemption.My violation of
Section 7031.5 by try applicant fora .it aubjttu the applicant to a civil penalty of 314a4Z 01g1ber00 Occupancy Type
nm mom them five hundred doors 01500).
❑1.u owner errme propcny,err my wployees with wage as noir sole compenudon,
will do Ne work,and the swctus is not intended uroffemd forsale(Sec.7000.Business
and Professions code:The Contractor:Licemn sew does mut apply 0 an owner or - Required Inspections
property who Wilds.r impmm thereon.and whodoessuchwerkhimxlror through his I.J?1
own employee,provided that such improvements menot intended oroRered formic.If. u p/b :
however.me Wilding er impmwment is wld wimin om rut of mmpledon.the owner- P
builder will have the poem of proving that he did not build or improve for propose of t /
1.as owner of the property.am exclusively contracting with licensed contractors in
onsuun the pmjca(Sec.7004.Business and Professions Code:)The Comment's Li-
sena,hw does not apply to an owner of pmpeny who Wilds or impram memon,and.
whocomacts Watch pmjettswithncamracur(s)licemedpusuas stbe Contractors
Lim..Law, R Gr
❑l am exempt undo See. B&P C for Nis uon ,.
Dau I
WORKER COMP NSA RATION
1 hereby aRrtn under penalty of perjury one of IM folio� lantions:
�
I haw Find will maintain a Cmilicareof Comortoself-imum for Workees Compen- -
mioa as provided for by seed..3700 of th.Latercode,for the po forme nto or the
work for which this Permit is issued.
1 haw and will maintain Workers Compensation Insurance.as Fostered by Section
3700of the IAWr Code.for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number as:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITissection need not becomplcud ifft permit is formal hundred dollars(SIM)
Fir less.)
I ocniN that in the perfmsance of the work for which this permit is issued,I shall not
employ any Pelson in any manner all as in become subject o the Workers'Compensation
Laws of California.Das
Applicant
NOTICE TO APPLICANT:IL after making this CeniEcam of Exemption,you should
become subject to the Worker's Compensation provisions of the IaMr Code,you most
.,Z forthwith comply with such provision or mu Permit shall be deemed rerokod.
Z O CONSTRUCTION LENDING AGENCY
[+ 1 hereby of itrt dot inert is a comuucd.lending agemy Int dm po fmmamx of
CLtM work fur which this permit is issued(Sec.3097,Civ.C.)
GQ Lender's Name
7-. Undcrk Add.
U C I certify that I have read this application and suss that the chow information is G-'
Iy (~ correct I agwe to comply with all city and county ordinances and sort laws relating to
C)C.7 building construction.and hereby amhonae neprcacntatims of this city to man upon tM
al o c-brmuu.cd property for inspection purposes.
(We)agree to saw,indemnify and keep humless the City of Cupertino against
rq
liabilities,judgments.costs and expenses which may in any way accse against said City
V Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO RCE REGULATIONS.
n f��G�pY /
s trmorApV_CIxe a Dam Re-roofs
RI
HAZARDOUS MATEA ISC-CO� Type of Roof
Will the applicant OF future building Occupant smut or hvMlc hanrdous material
as derined by IM Cupertino Municipal Code,Chapter 9.13.and IM Health and Safety
couo,SectionCY.zss3uoT All roofs shall be inspected nor to an roofing material beim
❑Yin l�N. P P Y g g installed.
Will the applicant or Imre building«eupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as de0ned by the Bay Area Air Quality Management all new materials for inspection.
District]
❑Yes C Nu
I have mad the hvarm usm�aterialsrequirementsunderChapter6,95oftheCalifor-
.iaHeulth&SafetyCede.Seembs 255(15,35533 and 25530.1 undersand Net ifde Wilding
dace not currently haw a tenant tont it is my respeo ihility to motif y dtc occupant or the
requires cnuwhKhmuaMmepriorreiuuanttofaCrnirm.wof capon Signature of Applicant Date
r or authomcd agent ,� All roof coverings to be Class"B or better
Community Development
F 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT#
OWNER'S NAME: M(c,j+ PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: 1 u ^ Q Z 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 C
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
h Plumbing u pr�L{i - LS D
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
YUP c.�a,1 12
Owner/CConon r Signature bale
au
CITYF ORN� �PER�INO
CUPEkTINO PERMIT APPLICATION FORM
APN # ! / / D Date:
u ( l2 ?.I o
Building Address:
2-Dz q--3 NPX t N
Owner's Name: Phone #:
111 " QCs" Crib -24 -�2C0
Contractor: License #:
LI 'i 23 (,�
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
1 � �
Residential Commercial ❑
For Residential I stallations:
Attic ❑ 1s` floor/M 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 A proval Required Fj
Cost of Proje i Type of Constru Occupancy gro
Strapped On Platform Bonded Sq.Ft. Floor Area:
New Location ❑ Re lacem
Qty. if
A p 'cable Fee ID Fee Description Fee Group
! BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec t1, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Perini tlssue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
6 � 7� . 7 �
CITY OF CUPERTINO
F LJRNACE/AC
CUPERTINO PERMIT APPLICATION FORM
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