04060094 CITY OF CUPECQ �C*,TOR TNFORMArl.n
BUILDING DIVISIONSION PERMIT
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT N%4060094
20128 PACIFICA DR
OWNER'S NAME: - PERMIT ISSUE DATE
NAIDU BOLLINENI 10570 S DE
11
ONE: SANITARY NO. CONTROL NO.
(408) 861-9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOZO LICENSED CONTRACTOR'S DECLARATION
1 hereby arcom Net 1 are licensed under provisions of Chapter 9(commencing Job Description
ws Section 7omB of Division Sofdte B.,basmand fessions Coda,itdmylicenscis
bLl� ter r � andercemA A-1.,/ e� FURNACE REPLACEMENT & ADD A/ � LE
S�? L en tea Lic.g
Cunuxeton <-
yes Fund my plans shall heuscd uEpL9RC4.10
JUN 21 2004
�yU
3 Licamcd Prommionel
OWNER-BUILDER DECLARATION
I I hereby affirm Nal I am exempt from the Conlmctor's License Law for the BUILDING
a oO following reason.(Section 7113 1.5,Business and Professions Code:Any city or county
q which requites a permit or comuuci,elect,improve,demolish,or repair any stmclum
Fiy Pdonn its issuance,also requires the applicant for such Permit to file a signed statement
< That he is licensed pursuant 1.the pmvislomofMeContractor'aLianseLaw(Chapter 9 Sq.Ft. Floor Area Valuation
y�F (commencing with Section 7")of Division 3 of NB
C mineseand Profanation;Code)or
O ey^$ that he u exempt therefrom and Ne bring for the allotted exemption.My votedon of
Seetlnn 7031.5 by any applicant for a permit Subjects the appfremt to a civil P..hy of e10 0Occupancy Type
not more than Rm hundred dollars(5500).
❑I,as owner of the property,unity employees with wages u their role compensation,
will do the work and Ne swaum is notintended on offered fusels(Sec.7044,Business
and Pinfamons Code:The Commgtora Llama Law dors not apply to an owner of Required Inspections
property who
bull&or improves thereon.and who items such work hitnadf or through his
own employees.provided that such improvements art not intended or offered for sole.If.
however,Ne building or improvement is sold within one year of completion,the Owner.
builder will have the burden of proving that he did not build or improve for purpose of
tile.).
0 1.as Owner of the progeny,am exclusively contracting with licensed contramors to
mmwct me project(Sec.7014,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or lmpmves thereon.red,
who contracts for auch projects with a con iactor(s)licensed pursuant to the Contraclofs
License Law. 1
0 1 am exempt under Sec. .B&P C far this resson
1307'
wner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
I ham and will maintain a Ccnificaec ofComenuo self-insure for Worlds Campen- -
wn,u provided for by Section 37110 of me Labor Code.for the performance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,ss required by Section
00 of the labor Code,far the performmec of me work for which mice Permit is issued.
dPolicy.numljeram:
3;rr. . IY E T •GATE OF EXEM OM WORKERS'1
COMPENSATI NSURANCE Ir .J
(Thi rection need nm bccompleted if the Permit is futons huntlrttl tlolW(51IX1)
or less.)
1 sonify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manners as in become subject to the Warken'Compensation
Laws of California.Doc
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
became subject to the Worker's Compensation previsions of the labor Code,you must
�Z forthwith comply with such provisions or this panni(shall he tlamed revoked.
Z O CONSTRUCTION LENDING AGENCY
[r I hereby affirm mat mem is a mmatractim.lending agency for the iamfurmancc of
lYi a7 the work for which this permit is issued(Sem.3097.CO,C.)
QLenders Name
Lenders Address
U I certify met I have mad this application and sole That the above information is
V.F cancer.I agree to amply with all city and county on inareas and state laws mining to I
0 C.) move-immi..it Pro mtl hereby itthonpl representatives;of this city tocnecr upon the /1
W above-me e)ogre progeny for taciturnity
t keep es.
(We)agree to cove,indemnify and keep harmless the City a against
against
U y in
un¢grantand expenses which they in my way accrue against unit Cily
(„)z in consequence of the gritting of This permit.
PT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: D
URCI II
URC EGULATIONS.
Re-roofs
ignemrtof Applo"HAZ RDD De
HAZARDOUS MATERIALS DISC' Type of Roof
Will the applicant or future building occupant store orhandle harmdous maecfial
u defined by the Cupertino Municipal Cade.Chapter 9.12,and me Health and Safety
ads,Sachin 25532007 fa All roofs shall be inspected prior to any roofing material being installed.
Cl
Will the applicant orre building ocapant use cyuipmem an devices which If a roof is installed without first obtaining an inspection,I agree to remove
cell haramous air cantaminants m defined by me Bey Area Air Quality Management all new materials for inspection.
DisuicT?
❑Yes / No
I have mad the monstrous materials requimments under Chapter 6.95 of the Califar-
nigHcal cu afetyCotle,Scctiam 25505.25533 itd25534.1 understand tholilmc building
desn
nen0y ham a ecnenx mat it is my respomihiliry to notify the proupitt of me
re me wNc mmthcmetptlorwiuvanecofe '0camofOccu Signature OfApphcan[ Date
Owner or aushorivatl ottani ec All roof coverings to be Class"B"or better
a Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS- PERMIT#
OWNER'S NAME: j ' PHONE # Zl (Q'
GENERAL CONTRACTOR: U
I.am not using any subcontractors: i V �i�/ �/�
Signature
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
�l
Owner/Contractor Signature Da 'e
CITY OF CUPERTINO
FURNACE/AC o
CUPEkTINO PERMIT APPLICATION FORM
APN # � rJ �/ p��Z Date: � // v
Building Address: ` V /
Pa-c
Owner's Name: Phone#: , ✓! r
Id L ✓/ � �J
Contrac or: Phone: License#:
, 4og-�62l- '6 � Z 1
Contact: «� i / Phone: f/ .�� Cupertino Business License#:
Y(k (/� l cJ iv
Building Permit Info:
Bldg ❑ Elecpff Plumb ❑ Mec13'to,
Job Description:
ResidentialCommercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"a floor❑
Adhere to min set back 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: t Type of Construction: Occupanc group:
�9Zr c� -
Strapped ❑ On Platform ❑ Bonded ❑ Sq. t. Floor Area:
New Location ElRe Iacemenz--
Qty-If.
li le Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 c8n MECHANICAL
BREMAHAN A/C Units <= 10, 000 cfin MECHANICAL
IR
BREMRECEPT Rec tI, 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 BUILDING
BUSLIC Business License BUILDING
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