05020136 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACT
, ORINF�ORMATIO
BUILDING ADDRESS: ALL TEMPERATURE SERVICE AI PERMITNOOS020136
ER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uO0 LICENSEDCONfRACTOR'S DECLARATION Job Description
C I hereby affirm that
1 am licensed under provisions of Chapter 9(commencing
b wish Scction7")uf DiAsionJoflhe Busineuand Profeuiom Code,azdmylicenuis
imfull perceived erle
? License Class Y REPLACE FURNACES (3) / AHS (2)
DOW O Lk.
ZZ , Da7- --o torrau .. CONTRACTOR: ALL TEMPERATURE SERVICE
rj ARCHITECTS DECLARATION
�i I understand my plans shall W used as public mwrds
Dau
Limine d Professional
OWNER-BUILDER DECLARATION
iP 1 herchy affirm that I am exempt from the Contsmmrs License Law for the
00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
9 which requires a permit to cmnrml.site,improve,demolish,nr mpoir any articarc
prior to its issuance.also mtIuims the applicant for such permit In file a signCd ataamcm
that he is licensed pursuant o the provisioes of to Common's Ue,rem Law(Chaptcr 9 Sq. Ft. Floor Area Val(�CjFL90 OO
�Fa (oommencing with Section 7")of Division J of On Business and Proica ions Code)or
in Nat he is exempt therefrom and tbe Ease for the aleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of APN Number Occupancy Type
not more Iran eve hundred dollars($500).
❑i,u ownv of Ne property,or my employees with wege u their sale compewtlon. 32634071 . 00
will do the work.and Meswmure u not intended oro@red foram(Sec.704x,Business
and Pofc rm.Code:The Contractors License Law does not apply as an everter of Required Inspections
property who builds or improves thereon,and who doessuch warkhimulf or through his
awn employees,provided that such improvements arc not intended oronered formic.If.
however.Ne buildingvMetorder of ovinissoldwithinone year of completion,Ne owmrf
Wilder will love tin burden Improvement
ement i dust he did not Wild or improve for purposeMe onto of
wile I
❑I,as owner of the property,am exclusively contracting with licensed cormsemis to Y/
ono,La the project(BCC.o in wneBusr ofr and rtyProfessionswhWi Code:)The CnnUdeon, Ll-
.he Lawdoesneupplr ma,ownerofproperty who Wdporimprove Motion,and,
who cat Lace for such projects with a contnetor(s)liceued pursuant m the contractors
LkI am Law. ^�
1 am exempt under Sec. .B 4 P C for Nis rcuon
ncr Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury we of the following decluatiou:
❑I have and will maintain a Cer9reaa of Consent m selr-insumfor WorkerSCompen-
sation,u provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maimain Worker's Compensation I...as inquired by Section
3700 of the Labor Code,for the performance of Ne work for which this permit is issued.
My Workers Compensation lasurentt carrier and Policy number
Ca er. SdIFo ( OM " mj"7": W 7 %(//2
CERTIFlCA OFUEMPI'IONFROMWORKERS'
COMPENSATION INSURANCE
This section need not becompinN Uthe l c mit Is boom,hundred dollars($100)
less.)
I certify Nat in the performance of the work for which this permit is issued.I shall not
employ any person in any manocrsn as ii become subject to IW Workeri Compensation
Laws of Califomia Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Cenifea¢of Exemption,you should
become subject to the Worker's Com,noun ion provisions of the Labor Code,you must
.JO foMwith comply with such provision or this permitahall W dccmed revoked.
z'-" CONSTRUCTION LENDING AGENCY
[—r I hereby al0rm Nat there is a construction lending agency for Ne performance of
(La the work for which his permit is issued(Sec.3097.Civ.C.)
6W. A lenders Name
z lenders Address
U C I certify Nat 1 have mad this application and sum,hat the move informadun u
F comet.I agree to comply with all city and county ordinances and sate laws totaling to
�U building construction.and hereby authorim repomwolves Ofthie city to enter upon the
above mentioned property for inspection pugmsca
HG (We)agree to save,indemnify and keep hamkss the City of Cupcnino against
re, Indiliue.judgmena,eoasand,i,.which may in my way attn,e eg.minsaid City
U z APPs Permit.
LICANT UNDERSTANDS Anesequicnion of Me Standing of tND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. kL
Re-roofs
Signature of ApplicanUComr Guide, A�La
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant Or forum building occupant stere or handle hanrdous maurial
Alft Oerned by Uw Cupenimo Municipal Code.Chapter 9.12,and the Health and Safety
.Section 255]2(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes l.TNo
W,II the applicant Or future Wilding occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cont ha=Zo air conuminana as defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes )<No
1 have read the Wuardous materials requirements under Chapar6.95 of the caliror-
rusI th&safe
oae,Sections 255115,25533 and 25530.1 undersand that if the Wilding
doe not cu y ave a¢nen et it is remomibilit,a notify the occupant Or the
recut remei w'I in poor muccofa Ceruilcaw ofaeupaney. Signature of Applicant Dale
3-t5--
OvmC,m thM,cd.genl Date All roof coverings to be Class"B"or better