04090280 I CITY OF CUPERTINOORxINFORMAr
BUILDING DIVISION PERMIT Y,CONTRAC-`TTION
£ _ ":• '_'• ° .' -` -
BUILDINGADDRESS: A PERFECT CLIMATE PERMITN04090280
1'
OW NER'S NAME: PERMIT LSUE DATE
SREEW
NE:
SANITARY O. C OL NO.
(4nR) 1861 -9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that ce
0110 1 am licensed under provisions ofCode, 9(commencing -JOb
withScctian] 7 of Division Sof the Business and Profmssm inCode,and my license is
ImmH mreaand effect.q
Fe LlREPLACE FURNACE
Licenseclaaa Lic.a
[ p Date DECLARATION Cun c
.ARCHITECTS DECLARATION JAN' f9 '2005
IundcralanJ my plans shall heused as public records -'-
DyU
C y Lucnscd Pmfmssional {( ppp
U
--- --- --
Q S OWNER-BUILDER DECLARATION
a 0 rl {I
Y<E 1 hereby alfirm
that 1 am exempt from the Contractor ®�s License Law for the - N`VJn
following mason.(Section 71131.5,Business and Professions Code:Any city or county
E$ which requires a Imrmit it,con tinsel,also,improve,demolish,or repair any sticture
yZ> prior to its issuance.alio recimseS me applicant for such permit to file a signed statement
i< at he is a
focused Sq.Ft. Floor Area Vanua[on
th ._
x t-� (commencing with Section 7")of Division 3 of the Business and Professions Cook)or .
_ that he is exempt therefrom and Ne axis for the alleged exemption.Any violation of
Section 9031.5 by any appliant fan a permit subjects the applicant to a civil penalty of 3-MMIIII)VO 0 - ' Occupancy Type
not mom than fm hundred dollars
1,as owner of Ne pmperty.or my employees with wags as Chir sole compensation,
will do On,work,and Nc awnure is nm intended or offered for ask,(See 7044.Business - -
Required Inspections
and Profusions Cade:The Connector's License Law Coca not apply to an owner of
preperlywho builds orimprovesdemon,and who doessuch wart himselfur though his -
own<mployete,pmvideddtatsuchimpoements aonatina:ndedoroRared moraine.It, -
humeven Ne building or improvement is sold within one year of complcuon,the owner- - - - -
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
MI,as owner of Ne property am exclusively eonlneting with licensed contractors to
construct the pmjecl(Sec.7044,Business and Professions Code:)The Contirmum's Li.
Cense law does not apply in an owner of property who Wilds or impmvea Ihmpn,and - -
whocomractsforsuchprojectswithacommuclor(a)licensed pursuant to the Contractors. ..
LKCose Law.
l son exempt under See ,B&PC far thisnano
Gwnd 2C-ElY ,7Ft Sar EKFfN TRIA-✓,Dale
YY WORKERS COMPENSATION DECL ATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
I have and will maintain aCe tifiente of Carvenuo self-insure for Workers Compcn- _
ion,u provided for by Section 3900 or the labor Code,for,due e performance of the
W for which this permit is issued.
I have and will maintain Workefs Compensation Insursna,as required by section
00 of the Labor Cade.for the performance of the work for which this permitis issuedy Workers Compensation Insurance ani.and Policy mother arc:
rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nal h completed if the permit is foranc hundred dollars($IW)
or las) _ _. •.
1 certify,Nm in Ne performance of the work for which Nis permit is issued,1 shall not
employ any person in any manner an as to become subject o ft Workers'Compensation - _ -
Laws of California Date -
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject an th Workers Compenauon provisions of the IaWr Code,you mans
0Z fonhwilh Canopywith such provisions or this permit shall aa deemed revoked.
Z Q CONSTRUCTION LENDING AGENCY
I hereby affirm thin there is a construction lending agency sof the peffurmance of
D: 7 the work for which this permit is issued(Sec.3097.Civ.C.) -
(31 Undch Name
Lenders Address
VQ 1 cenify that 1 have read this application and some that the then informadun is
L. f" corr«L I agree to comply wish all city and county ordinances and some laws mlating to
O U building construction.and hereby authorne mprescnotives of this city to enter upon the
T L63 shove-ounuoned properly for inspection purposes.
(We)agree to ave,indemnify and temp hamlesv ft City of Cupcnino against
F-' N liabilities.judgmeno,costs and CxKnsu which may in any way Came against said City
U Z in emoccLu mo of the granting of this permit E
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU ATIONS.
'�� Re-roofs
Signaure of Apylicam/Contractor Date
HAZARDOUS MATERIALS DISCLOSURh Type of Roof
Will the applicant or(atlue Wilding«C.Lo nt stare ar handle Mendota material
u defined by th Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to an roofing material being
E3 Y- MN.
P P Y g g installed.
Will thea applicant or future building t tree equipment or devl4ca whim If a roof is installed without first obtaining an inspection,I agree to remove
rap s«capon gmipmen
not ha'rardous air contaminants as dchncd by the Bay Area Air Gustily Management all new materials for inspection.
District?
❑yma b N&
I have mad the uuvasdnus mum itxrequisomcnts under Chapmr6.95 of thc Cilifor
.is He9th&Safe,y Code,Sccuom25505.25533 and25534.I undersand Nal ifthc Wilding
doer nal cunend no'
a mnanL Net it u my m3pean ihilily to army the occupml of the _ -
oquhmjs ' upbemet pnp)toiaaamcafac.uhamafOm4p y' Signature of Applicant Date
f inn f .Z 0
p aratr boriaedagent Damm - - All roof coverings to be Class"B"or better