04120012CITY OF CUPERTINO
DIVISION PERMIT
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Alender's
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€CONTRACTORINFORMATION-',
BUILDING
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BUILDING ADDRESS:
A PERFECT CLIMATE
PERMIT No04120012
22047 CLEARCREEK CT
OWNER'S NAME:
PERMIT ISSUE DATE
PATTY FAIRCHILD
10570 S DEANZA BLVD
12/01/2004
ONE:
SANITARY NO. CONTROL N0.
(408) 861-9545
ARCHITECrIENGINEER:
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BUILDING PERMIT INFO
LOG ELECT PLUMB MECH
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DECLARATION
Lm
Job Descri On
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1 hereby affirm Nu 1 am Ilanad under pmvisi s of Chapter Y (commencing
On, IDCONmard Or ,
N don 70110)of Divii 3oflW Business aM Sion Cade. and my license is
arae ma ercecy:a�
REPLACE FURNACE
(,
U Mso Class l Lies
Gammnor
DECDat
EC 4 1004
raUand my pGru x �' pabV anr�
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Licensed Proressio od
OWNER -BUILDER DECLARATION
I bomhy .Rion n 1 em exempt from the Conuactoh Licimse for Nc
following mason. o To L5, Business and c ty o
emoli Code: Any city or
ere. tine
moria eltee improve, demolish. ore
which rtyuirm a permit or construct.
ed swcuro
0
Sq.. F[. Floor Area
- Valuation -
On. asig
prioru)its issuance. . rt tothe the applicant for such permiuo01cssignedsutemem
that Wiecing witpsectiol total of lW Ctu usiner a Li xnxhw(Chap¢rY
of Division orlWeged Business Cork) or
Any violation
Nat he u exempt therefrom and the baso for the alleged exemption. Any violation of
tatheiisexewithhecGon and On basis
¢ 0
.. Occupancy Type
Section 7031.5 by any applicant for a permit subjects to applicant m a civil penalty of
not mom Nm Bvo hundred dollars (5500).
❑ 1, as owner of IW properly, or my employees wit wages ax their sole mmpenaadon,
Required Inspectionst-
will do tire work, and the swctuse is not intended or offered for ale (Sec. ]040, Business
and Pmreasions Cade: The Conmctor's Wane Law toes not appy m an owner or
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propeny who builds or improves reran. and who docs such work himself or mmugh his
own employers, provided Nat such improvements art not intended oroffemil forsale. It,
however. the building or impmvemem is sold within one yen of compledon. Ne owner.
builder will have Ne burden of proving tat he did nm Wild or improve for pu boo of
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.1, L
❑ I, u owner of On property, am exclusively eomrae,ing with licensed conuumrs m
Construct the project (Sec. 7004. Business and Pmfersioru Code:) The Contnchoes Li.
_
Most, Law docs not apply to m owner of pmpeny who Wilds Or improves tcro n, and.
who contracts far such projects with a eon0actor(s) licensed pursuant to to Comraclor'a
License law.
❑ 1 am exempt under Sec. . B S, P C for this reason
Owner Dat
WORKER'S COMPENSATION DECLARATION
I Wmby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Contain, to self -Insure for Workers Compcn-
ation. as provided for by Section 3700 or the IaWr code. forte performance of to
work far whim this Perini, is issued.
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❑ 1 have and will maintain Worker's Compemnion Insurance, as required by Section
37W of the Labor Code. for Ne performance of On work for which this permit is issued.
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MyWorkrexa �o.mp=donlnauranmcamumdF�p�livcyn✓usmberam:
C}vipr- 'MLkrr�-9n/�� poliey-yd.:aT 101l194�
CERTIFlCATEOFE%EMPDQN OM WORKERS'
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COMPENSATION INSURANCE
(Thissectinn nred not W complca:d if tic Knit is fortune hundred dollars ($100)
'
or Less)
1 ceNfy Na in to arformanec of the work for which this permit u issued. 1 shall not
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employ any pnsan in my mannerso a in become subject to tite WarkeR Comperlammon
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cenifica c of Exemption, you should
become subject to the WarkG s COmpcnadaa provislom of dm Labor Code, You mum
foMwith comply rids such pmvisiov or Nis permit shall W deemed revoked.
UCTION LENDING AGENCY
CONSTRUCTION
thi Wt mere is a
1 Mr them 3 lending agcnry for the Performance of
which sound(SO ..
work Nur which Nu Penni, is issued (SO. 7041, Civ, C.)
Le Name
Lender's Addreu
I ttrtify Nat 1 have read this applicarion and sum that the above information is
correct. 1 agree to comply with all city and county ordinsom and sure laws relating in
building construction. and hereby authmice rrprescmativcs Of this city to enter upon the
above-nimunmd property for inspection pampers.
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(We) agree to ave, indemnify and kap harmless the City of Cupertino agammt
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liabiliuu,judgments, ensu and expensea which may in my way accauc again said City
in consequence of the granting of this permit.
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APPLICA _UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU REG L-A't1ONS.
Re -roofs
Type of Roof
igna,urt ofApplica-d ARDOUS MATERIALS DISCLOSURE Dare
Will dm applicant or future building oceupmnam or handle havardous material
as defined by the Cupertino Municipal Code, Chapter 9.13. and IW Health and Safety
ode. 0 ea zss3z(a)+
❑Yes
All roofs shall be inspected nor to an roofing material being Installed.
P P Y g g
Win the apitheand m ten boa aeatupam or device.;
If a roof is installed without first obtaining an inspection, I agree to remove
g ase equipment whim
rout hwardoas air mnmminam u d recd by the Bay Arca Air Quality Management
all new materials for inspection.
DisuicR
❑Yes 110NO
1 have mad Ne hvaNnus materials rtyuirtmcnu under Chapmr6.Y5 of Nc Caliror-
nia HcalNd Safety Codr,Scclium25Y)5.25533md25534. lundersundtxtirtc Wilding
does not currtnd mw1l Fn l tat it is my mspomibiliy At notify the occupant of me
requmen an metpnorn,iaaanaaracrmnralearormpaay.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or agent„