03120110 (2) CITY OF CUPERTINO y'� +�*♦s-.T= a�t,,T�y� 'n*,g % .,,; -
BUILDINCDIVISION PERMIT �".CO vf�.[�ACTORi11111',O1�,MAT,10"i k,t.
auILDINGADDRESS' A PERFECT CLIMATE PERMIT"03120110
it
NER'S NAME: PERMIT ISSUE DATENE: SANITARY NO. CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
lies, LICENSED CONTRACTOR'S DECLARATION lob Description
tlwF I berchy affirm that l am licensed under provisions of Chapter 9(commencing P
<2 with Section7M)) D' si o3of Neeusinmaand Pm i od ndmylicenseis
in fullfnrcea e et. REPLACE FURNACE
njP�IZ License a TSD FIN^LEO
DdM (,'pnlraClef
q AR TE-CTS DECLAR T
2 1 undcc rand my plans shall he used ea public rani s
^off
Licensed Professional JAN 1 3'2004
OW NERBUILDER DECLARATION
<E 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
O O following reason.(Section 7(61.5,Business and Professions Cade:Any city or county
K$ which requires a permit to construct.alter,improve,demolish,or repair any structure
Leri prior to its issuance.also ociuime the applicant forsuch permit to file a signed statement
pp <
that he is licensedfumuanuo the provielmoofthcContmcmr'CLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
y $ (commencing with Section 7")of Division J of the Businessand Professions Cade)or
It
a. at he is exempt therefrom and the basic for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3gr00 Occupancy MN.*Nb* Oe
not mom Nan five hundred dollars(5500). P y TYP
❑T.to owner of the property,or my employees with wages a their sole compensation,
will do the work end the awnum is not intended or offered for sale(Sec.7044.Business
and Profession Code:The Contractor,License Law tinea not apply to an owner of Required Inspections
property who builds or improves themon,and who does such work himself or through his
own employees,provided that such improvements are not intended oro@red formic.If,
however,the building or improvement is sold within one year of completion,she owner.
builder will have the burden of proving that he did not build or improve for purpose of -
side.).
❑I,as owner of the property,em mdmively contracting with licensed Conmcmrs to
construct the project(Sec.7044,Business and Professions CWe:)The Contractors Li.
came Law docs not apply to an owner of property who builds or improves thamon,and
who Contracts for such projects with a c rrilmlor(s)ticensed pursuant m the Contractors
License law.
❑1 am exempt under Sea ,B&P C for this moron
Owner Dem
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of fie following dalaretions:
eve and will maintain a Certificate of Consent o ulf-insum for Worker's Compeer
n,as provided for by Section 3700 of the labor Code.for Ne Performance of the
for which this permit is issued.
Iave and will maintain Worker,Compensation Insurance,as required by Section
37Mthe labor Cods,fit Ne pesformanec of Ne work for which Nis permit is issue¢
My W ker' a i monoclV licy nu er F
Carrier.
CRTIP 'fie 0f EXROM ORCER '
COMPENSRANCE
(This section need not M comPlemd if the Permit is for one hundred dollen ri 100)
or less)
I certify thus in the peffornome.of the work for which Nis permit is issued,I shall nut
employ any formal in any mannerso as to hecume subject to the Workers Compemadon
Laws of Cidif oni..Data
Applicam
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compcnmtion provisions of the Labor Cook,you mush
.JO forthwith comply with such provisions or this Permit shall be deemed revoked.
'z CONSTRUCTION LENDING AGENCY
'rpt F�-t Ihereby affirm that them is a construction lending agency for the kofurmuce of ..
K the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
5 z Lender's A&Wkx
U Q 1 certify that 1 ha d this application and state that the above information is
W F correct.1 agree t.cam ith all city rad county ominances and state laws adming)o
V building canswcfian hereby au fiereprmenmtives of Chia city to enter upon the
W ahovcmcmintedP rty forire rpssm.
L�.at gy (We)at. o save,inde and cap hawlem the City of Cupertino against
it h liabllitim,jud ma.casuan act ich may in anyway same against said City
U Z in ourself of the gmnti rax is per it.
ARE Li UNDERS N AND ILL COMPLY W A L NO -POINT Issued by: MJi Date
SOU E GULATI S.
Re-roofs
Signa mofAppland.196oloactor to
H ARD US MATERIALS DISCLOSURE Type of Roof
Will applicant ser .Tum building mcupanumto or handle amokimmveriel
m cfinc y the Cupertinocipal Coda Chapter 9.12,and the Heald and Safety
de, tern zssJz(a)+
❑Ym u All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, agree to remove
iection,I
Will the applicant mm ing occupant tau cyvipment or devices which P
,it hmardnua air Cents i ed by the Bay Area Air Quality Management all new materials for inspection.
istrin7
❑Yes
Ihavem NCh rdous ria quimmcntsundcr Chapmr6.95of mCalirar,
nia Hted"S tyC ,Soto. 5505. 33 and 25534.1 onsersund thin if the building
time not err fly h a to 1,Nat it i an spunsihility to andly the ta: pent n the
requimmcn wore must met prior I uaaaofaCertificatea, p t Signature of Applicant Date
Ow nn'.edagent Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
FURNACE/AC v L J
Of
CUPER-TINO PERMIT APPLICATION FORM
APNAAd&ess:7Z a3JDate:
Buil
Owni Phone :yC4(v -2 7 /
Contra or: Phone• --
License#:
l
Conta Phone: Cupertino Business License #:
Building Permit'Info:
Bldg ❑ Elect P5 Plumb ❑ Mech
Job DescriZi
p(Q Ce / - - v� I vi 4XS�
ResidentialCommercial ❑
For Resideations:
Attic ❑ I"floor u 2"d 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 PlanningA roval Required
Cost of Proj <� V Type of C ns ction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
n
Qty. if
51"
Fee ID Fee Description Fee Group
GY Ener BUILDING
FURN Relocation of Furnace MECHANICAL
ACOVER A/C Unit > 10,000 cfm MECHANICAL
AII2HAN A/C Units <= 10, 000 cfm MECHANICAL
RECEPT Rec tl, Switch & Outlets ELECTRICALICRE Seismic Fee Res BUILDING
ITFEE Elec Permit Issuance ELECTRICAL
TTFEE Mech Permit Issuance MECHANICAL
ITFEE Plumbin PermitPLUMBING
FEE Bld Permit Fees BUILDING
CHK Plan Check Fee BUILDING
Business License BUILDING