04010082 (2) CITY OF CUPER't'INO
BUILDING DIVISION PERMIT 46ONTRACTWINFORMATIO.N:
eu1LDINGADDRESS: SPECIALIZED HEATING & AIR MN004010082
41 (-1�17171<T,TNR MR
OW NER'S NAME: PERMITLSUE DATE
ONE: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o o LICENSED CONTRACTOR'S DECLARATION
d F1 bercby affirm Net 1 em lianud under pmvis o s of Chapter 9(commencing Job Description
with Section 7")of Division 3 of NCR.al nand Prafcuinm Ca de.end my license is
ra yinmBrorc an erre 7 O REPLACE FURNACE-ADD A/C
LZ License
O Dam Cantncbr
,✓ RCHITECI-S DEC ATION
T I undersand my plans ll W sheused' lic rtcord,
to6
go Licensed Proossi...I
9 OWNER-BUILDER DECLARATION
4 Q y 1 hereby.mere that 1 am1. exempt Trete the Cantonal. :Any C Law
y. for the
00 follwhnwin{mresa permit t Ofn LS,Business and improve.
de nm Coot:Any city structure
'z$ whichrequiresac..1s.recnmouct,alit,imprew,deermitt nrc,repair edxwnum
y hat
iuissusdpurinumquithe theappliesmforachpermiuoccome iv,(Chtemem
—�< (commencing
sccensed puntion70hc provision of the Canoacmt'and Prot sw(Chapmr9 Sq. F[. Floor Area Valuation
Fp$ teat he if xempth Scdion and th basison 3 th the B ail exempt on.Any vi Code)of
3� that he if exempt therefrom end the hues for the We{ed exemption.Any violation or rA�p�i.k,rs�..,,t,
Section 1031.5 by any applicant for a permit subjects to applicant to a civil penalty of 3 sakS LL ITJss$4!?esr0 0 Occupancy Type
not mart than Ow hundred dollars($500).
❑1,As owner of the property,or my employees with wages u their sale compensation.
will da Ne wank,and Om.net..is not intended or onemd tartale(See.1044,Business
and Professions Conic:The Connector's License Law dors not apply men owner or r Required Inspections
property who builds or improve Nemon,and who does such work himself or through h'
Own employees,provided that such improvements ere not interWetl oroRered forak.l!
however,Ne building or improvement is sold within oro Kar of rnmPI
ii' or ,
will have the burden of proving that he did not Wild or improve for purpose
ale.).
❑1,As owner of the property,am exclusively contracting with licensed canmc ZI
construct tc project(See.701 Business and Professions Code)The Conmaco.ls Lt.
come Law does not apply to an owner of property who Wilds or improwit Nemon,and
who contracts for such projects with a cortrutor(a)licensed pursuant to dte Contractor's
License Law.
❑I am exempt under Sec, .B @ P C far NIs moon -
Owner Data r _
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlty of perjury one of to following declarations:
1 have and will maintain a Cenift of Cnnam to self-imum for Worker's Compen.
137B)
ion,u provided for by Section 3100 of lie ISWr Cade,for Ne Performance of the
rk for which this permit is issued.
i have end will maintain Wekcls Compensation Insurance,as required by Section
of Ne IsborCode.for Ne performance of Jan work for which Nil permit 1s issued.
Worker's C mpemalon sunnm earrie andPoI'ynumberart:r. ��"o�liq NA:
C Fie TE OF ON FROM WORKERS'
COMPENSATION INSURANCE
(This action need not W completed if the permit b far one hundred dollen 1$100)
or lea)
1 cenify 0.1 1.the performance of the wart for which this permit B issued,I shall at -
employ any person in any mannerso As b become subject to to Workeers Compemation
Laws of C.lifomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Co tiflcata of Exemption,you should
become subject to Ne Worker's Compensation provisions of the UMr Code,you must
wJO forthwith comply with Inch provision or this permit shall W deemed revoked.
'Z r-" CONSTRUCTION LENDING AGENCY
N
'e+ IMrtM1y.from that Ncrt its can(Sec.3nl,CmCgeney for de performamm of
ai w>-r the work for which this permit is issued(Sec.3091,Civ.CJ
A Under's Name
D z Lender's Address
U Q 1 cenify Net 1 haw mad this application and Sum that the.hove ort rrookm is
Iy Pcorrect.I agree to comply with all city and county ordinanxs and sure laws misting in
C) U building construction,and hereby authorize reprtanmiws of Nis city to enter open the
dshow-mentioned property far impaction putpmea
(Wc)agree m taw,indemnify and keep harmlea the City of Cupertino against
VrA li.billtlei,judgmenrs,costs and expema which req in any way accrue against aid City /
7 in consequence of the gmming of this permit
�•r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date l
SOURCE REGULATIONS.
'tel - Re-roofs
nuure fAp IicsHAZA m Date
HAZARDOUS MATERIALS ISCLOSURE Type of Roof
Will the applicant or forum building oecupam Smrt of handle havudoui material
CIA
do Med by Ne Cupertino Municipal Code.Chapter 9.12.and Ne Health and Safety
Cole,3ecdon 25332(il? t All roofs shall be inspected prior to any roofing material being installed.
Y. P'r
will tc applicant or futum Wilding occ use cyvipmant ar dcviwa which If a roof is installed without first obtaining an inspection,I agree to remove
It havaralai air conmminanu u d tW Bay Area Air Quality Management all new materials for inspection.
sviet?
Yea
I haw read the h.aNimk materials mquirements amer Chaptar6.95 of the Califo>
.1.Boutin h Sacty Cade,Secloiu 25505.25533 And 25534.1 uMcmand that if Ne Wilding
does not currently have a Wheat.that it is my responsibility to rally the occupant of are
mquircmcnu ch most be Pdar .nccoracwnamaroecepancy. Signature of Applicant Date
Owner tar aulhorieeJ spam -We All roof coverings to be Class"B"or better
c � '
CITY OF CUPERTINO
CC
FURNACE/AC �8a
UPEI,TOAU/
INO PERMIT APPLICATION FORM
APN # � (f' � Date:
Building Address: VI I
7$L1 i t
Owner's Name: Phone
S' B S — bL
Contractor: P one: License#:
e 510 ian-sv--Z,
'Contact: Phon`ec:^ Cupertino Business License #:
KQV1n m Jr d lSL /+ G S3
Building Permit Info: y
Bldg ❑ Elect ❑ Plumb M ch C'J
Job Description: G
Residential Commerc I ❑ T�
For Residential Ins tions:
Attic ❑ 1` floor 2r 2nd floor❑
Adhere to min set back requirement❑
IWO
r Commercial Installations:
epIacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Pro �oject: oo Type of Const ructio I Occupancy o
Strapped LIJ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ElRe lacemerrf "�
Qty. if
Appliq6le Fee ID Fee Description Fee Gro
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
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC n Business License BUILDING
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