06040002 CITY OF CUPERTINOII
BUILDING DIVISION PERMIT �� IRACOY '.yd>Ct`l�'IATIfJPC"'-
BUILDING ADDRESS: SAN JOSE CONSTRUCTION PERMIT N006040002
22390 HOMESTEAD D
NII NAME: PERMIT ISSUE DATE
JAYNE HAM 1210 COLEMAN AVE 04/10/2006
PHONE: SANITARY NO. CONTROL NO.
(408) 986-8711
ARC HITECDENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 1 hereby affirm Wt 1 un licensed dolor pm isiona of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Business Pmo y and my license is
in fullfone and titre. g REPLACE EXISTING HVAC UNIT & ADD NEW UNIT IN
ueenhaQ Bag- ANOTHER LOCATION
v` bare C
u,85 ARCHITECT'S DECLARATION
I I understand my plans shall he used As u public records
yrs
cin Licensed Professional
0 3 OWNER-exempt frDECLARATION
C I Morey do.affirea(See Net 11. exempt(runt ten Cormacmo License Law for me
O o following Terson.(Smits 7113 L5,Business and ere,derurs Cade:Any city our county `^'
5$ which requires a permit re cores he alter.Improve,h permiil t coils pair any swcteem IS--
prior
"
_z'yr priorm iuiuusdp.alw requires he o forhachpemit Lice=Lw(Cha ream
€< thommenceemsed pursuant to tion701 of Division
of one Comrxmrati ProelAw(Codle) 9 Sq.Ft.Floor Area Valu
(commencing withthariores and the
D alis f r the
al egad Business And on.Any
Ction of V
�.. at
this he u exempt eMmfrom and tte btu far the alkgol exemption.AnY vlolauon of
Section 71131.5 by Any Applicant for a permit subjects the Applicant in a civil penalty of P Y YP
sat mart than frw hundred dollars(SS(p7. 3,Sy��yr27 . 00 7 . 0 0 _ anC 0
❑I,uawnv df die propety,eemY voPloyva with ngnsuthe'v had compenution, LO .LUL
will dothawork.and thouewctununutmmndedm ail does Ads apply
to
of Required Inspections
end Prowho
Cade:The vesdia car's ndwLicense Law doer out apply If an owner is q P
property who buiMa i imputesch Im oantwho amr a in auk himtril red Uuough his
owneer.then,progtedthatfotoimprowmenuincot year
orcoroRued ths, B.
builders.Neomi the u improvement u halt within me year of completion,the owner. .
builder will have the burden of proving that he did nor bulk or improve for purpose of
❑1.u owner of the property,am exclusively contracting with IlcenseE conouson to
corsuuct dee project(Sec.70ad,Business and Professions Code)The Cmuanmr's U.
cent Law am not apply to an owner of propenY who Milds or improves human.and.
who commcu for such pmjeces with a cantrector(U licensed puruamt To the Cmuuuh
Limens Law.
❑I mm tempt under See ,B•PC for this naso¢
er Dam
WORKER'S COMPENSATION DECLARATION -
1 hereby aRm under penalty of perjury ore of tic klbaing dmlumione
❑Ih.wand Milmainuins Ce flamof Conuntmnlf-insumfmWwkesCompcn-
utim,As provided for by Section 3700 of the Labor Code,ror the pe,(.m.m of the
work or which this permit is isem d.
❑1 hive and will maisWn Workees Compensation Insurance.as required by Section
3700 of the labor Code.for dte performance of the week for which this permit is issued.
My War ACmpe:=&.U0\inmmms mer and Policy rsa�n:
Cartier. _. r eY— Xy Policy No.: A i i
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
d
(Tom sectio coed net be completed tried permit is forone hundred dollars($100)
or less)
1 unify thei in the performance of the work for which this permit To usuetl.I shall not
employ any persen in any memories As in become subject to use Workers'Componution
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.ARcr making this Certificate of Exemptim.you should
become subjm To the Worker's Consternation provisions of the tabor Cade,you mud
.J O- forthwith comply with such provisions or then permit snail M d
doomed mocked.
z^y, CONSTRUCTION LENDING AGENCY
[-+ I hereby aRmm that them Is a cmmemcdon ending agency,for to Performance of
CL the work for which this permit m issued(Sec.3097,Ch,C.)
W Q Lendces Name
M)Z Lender's Add.
VQ 1 certify that 1 haw mad this Application and sum des,the above information is
U,;'" come.l agree u comply with all city and county ordinances sod sum laws elating m
OE building construction.and hereby authorin representatives of this city to enter upon dm
W almm-namuJ t preporty for inspection purposes
GajiNmen,
m um,indcoodly and troop harmless the City of Cupertino against
fn lia .ctrsandeapcunwnichmryinanywyaccrue.galMsaldCiqV VERND NL COMPLY WITH ALL NON-POINT Issued by: DateTION
t 15AI Re-roofs -��
Sig Igo:of ApplicaMCon our Dau
/ H US MATERIALS DISCLOSURE Type of Roof
Will the appllant or future Wilding occupant sham or handle hummons material -
rs defined by the Cupemine Municipal Code.Chapter 9.13,and dte Health and Safety
Soctim 35531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or future building occupant use equipment or dmlm which If a roof is installed without first obtaining an inspection,I agree to remove
emit haurdou air cmuminsru As droned by the Bay Area Air Quality MmaSement all new materials for inspection.
Dis IctT
Oyer CYN.
I hoe mad the hanrdausmaterials requirements underChapec 6.95ortheCalifor-
nolleed S myCode.Smtons25 ,25533"534.ImWemandthulflMMildin1
does It cuby haw a tenor at 'e mY mryansiniliry u notify ere cup t of the
requ' loco on M da anmaracemnmmor to OG Signature of Applicant Date
owner antharisd a cot V D,te All roof coverings to be Class "B"or better