04120045 CITY OF CUPERTINO - ° � ' -
BUILDING Dlv[SION p1 RiVIIT-- = kCONTRACTORhINFORMATI®N -- -.— "
- . BUILDING ADDRESS: A & H HEATING PERMrrNP04120045
1374 DEXTER
OWNER'S NAME: PERMITLSSUEDATE
EDWARD TILLMANN 770 CHESTNUT
NE: SANITARY NO. CONTROL NO.
. (408) 279-0722
ARCHITECT/ENGINEER: - UI IN.PO — — _-
P MECH
Lap LICENSED CONTRACfO ' DECLARATION
d C by sffirm Nut 1 am lice Prevision.of chapter 9(commencing Job Description
Z wia Se 70(111)af Division3af B ressand Pr.fcerimu Cude,andmyliceneir
�� in(vy ameandeffec REPLACE FRUNACE & A/C JAN /g 2005
,g? Li case❑au w Lic_.a .—
Z Da¢ - C.ntracwr
n—q4A CHTTECI'S D B U I UNG
W U I�edcrsuod my plans shall M used erode ��9UNG _
a Lice Prof sional •.
O OW NEmexemDER DECLARATION
con ION
ad a Y e berchy.(S. Nat I oro,Bump,(rote the Cndmis or License:AnyC taw for tW
m p O fallowing moan.Permit
to co s r Business and ovefessians Calc:Any oily m county
vi which requires a permit m uira the alter,impmsu h Permits at repair any swnute "
rsa prionnsliccuance,also
suamyo the theappfor suchPctor's Ecnuale a signed Law(Cha mem _
mmbeisficenwdpursaantmthepmvlsiansn oWe f
Business ndPrmlaonsCodw 9 Sq.FC.FIoorArea Valuation
(Commencing with anion and
ndUn Division of the Business and Professions Code)or -
y
that he is e¢mpt tbertfrom and tbe Ensu(or the alleged.empdon.Any violation of -
Section 7031.5 by any applicant for a Permit sibecu the applicant to a civil penalty of 3 2AMR&fibeiQ 0 Occupancy Type
not more Nan Eve hundred dollars(5500).
I,..wncrof the Property,or my employees with wags.Wer ax in mmpmadmion, -- -
.,Il& cwmk..dd¢swctuo:ianosin¢r darortemdforsdc(SM.7044,Business Required Inspections _
and Professors Codenm e
q
:The Contractor's Liceat Law does not apply an owner of -'
property who builds.,improv.thereon,and who d....h work himeelfor through his _ - -
own employe.,provided Nat such improvements arc not intended oro@red farrow.If. -
however.the building or improvement is sold within one year ofcompledon.the owner" -
Wild.,will have We Widen of proving Nat he did not Wild.,improve fur P.M..of
sale 1.
1,as owner of the property,am.elusively contracting with licensed rontraewrs an
construct the pmjm(Sec.7W.Business and Professions Code)The Contractor's Li-
cense Law dms not apply to an owner of property who Wilds or improv.Hereon,and. -
who contracts;for such pmjectswith acomracwr(s)licensed pursuant an We Contractors
License taw.
❑I rm.empt under Sec. .Bh P C for this,eaten
U Owner Date
WORKER'SCOMPENSATIONDECIARATION-
I lercby affirm under penalty of perjury arc of the following Melerationce
have and will maintain a Certificate of Consent to self-insure for Worker's Camper-
tan,as provided for by Section 37M of the labor Code.for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,.required by Section
3700 of the Iabof Cadc.for the pcdarmance a work far which this permit is issued.
Werk aCmareassum,lnsursncecarricr an wiry ower art:
C i Policy .:N/4tozesf7
CERTIFICA E EXEM O OM WORKERS'
COMPENSATION IIIANCE
(Thu section need not be completed lithe Permit isforonc hundred dollars(SIM)
or lass.)
1 cenifv Nat in the Performance of the work for which this Permit is issued,l shall not
employ any person in my manner so as w become subject o tW Worker:'Compensation -Law,of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifivam of Exemption,you should -
become subject to the Worker's Compensation pmvisions of We labor Code,you most
�z forthwith comply with such provisions or this Permit shall Ise demand rooked.
z O CONSTRUCTION LENDING AGENCY . .
se_+ I hereby affirm that there is a construction lending agency rot he performance of
a the work for which this panni,is issued(Sec.Myl,Cm Q
nest Q Lenders Name
raj z lenders Md.
U O 1 certify that 1 have read this application rad .in Nat the shove m1morrniun is
LU E' cmmtt I agree to comply with all city and county codlnan¢s and sure laws mlating w
0 Wilding construction,and hereby awfunim represcntaives of Nis city w enter upon the
r [37 above-mentioned property for Inspection purpnscs,
(We)agree to son.
demnify and keep
of Cupertino
st
tFi fad liabilities.judgments,coati and expenses which mabarriers
y inn any way we=against said iy
of to granting of this
U Z APPL CANT UNDERSTANDS AND TWILL COMPLY WITH ALL NON-POINT Issued by:S4tQ�( Date
SOURU REGULATIONS,
Re-roofs
7Will-
man murmur'r ^Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Weapplicant or fmum building occupant store or handle hmardous material
as dWe Cupertino Municipal Co ,Ch air 9,13,and the Health and Safety
al5533(,)7 All roofs shall be inspected prior to any roofing material being installed.
applicant or future building occupant tau cyuipmnnt or devils whicM1If a roof is installed without first obtaining an inspection,I agree to remove
tair contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection. '
vrict7 J
0Y. eRNts' .
1 have read the havvdous m derialsmquimmr us under Chapwr695 of the Califor
nu Health&Safety Cade.Sections 25505.25533 and 35534,1 undersound diatribe Wilding
it s not emrtnt one a wmnt,ibra it u my t.pomiEility w muddy We occupant of the
ray marts ichmotbemet - vane. a ricr ofOe.apaney. Signature of Applicant Date
o .,autharizedagert Data roof coverings to be Class"B"or better