01050015 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING,ADDRESS PERMIT NO.
22390 JANICE AV VALLEY HEATING & COILING 01050015
OWNI:R'S NAME APPLICATION SUR US]17
r
BONDS JOHN M A6ID LEE P 1171. N 4 TH ST 05/01_/2001.
� PHONE. SANITARY NO. CONTROL NO.
(408) 294-6290
0 ce O ARCHITECTAENGINEF.R: - BUILDING PERMIT INFO
pp Ell ELECT PLUMB MECH
Q�iU I=1 I-1 I=1 IJ
m LICENSED CONTRACTOR'S DECLARATION Job Description
_ 1 herchy affirm thin I am licensed under provisions of Chapter 9leammencing
E,_�w with Section 7000Jnr Division3 ufthe Mussiness anti Protession.s Calc.and my license
2.;; is"'parI...0.:lndell"' qq G � FURNACE REPLACEMENT.
_z I,icera Class CK Lie.Mas S/
w s N nate fir—lis contractor- pr_
ARCllll'F.CI'S DECLARATION
1 meant n al my,plan,shall tie used a,public rmords
to
ce
�to
a S Y Licensed Prom,imad
OWNER-EUILIIER DECLARATION
LL 1 hereby affirm that 1 am exempt from the Contractor's License Law for the -
C " hdlnwing reason.(Section 7131.5.Businessand Professions Calc'.Any city'a only
S F p wh y . I p ill i Itdemalfish.(IF mpairy sntuurc
i3o pa, I t I I to appli rl : bpm t fl g d tme.war
that he is licensed!pursuant t the pr of the Contrancene,License La (Chapter9 Sy. Ft. Floor Area Valuation
(conmencng woos Section 70M)of Division J of the.Eusnes and PmR..t ,Cade) ��
or that he is exempt therefnm,and the hu.sis for the alleged exemption.Any violation $2300
al Section 71315 by 1toy:tPPllrnnt for it permit subjects the applicant to u civil penalty
of Fiat mam than live natured dollars(S50o). A PN Number Occupancy Type
0 L as owner none pmptny.or any employee,with wase aS their sole comma ttion. 35701052. 00
will Jo the wmk.-and the strucrare is not immard Fir offered far sale(See.711LL
Bus and Pmre. +ns Code:'n,e Coon ctor'I Llecnde Law does not al,ply n,n Required Inspections
Business of pmpeny who builds of iespeaves thereon.and who docs such work himseli 301 — ROUGH PLUMBING
or through his own employees.Provided that such impmvemmms arc not intended or
ofT and for sale.If,hawever.the buildia,ar improvement is aid within one Yeat of 303 — ROUGH MECHANICAL
completion, wownor-hudder w ill have the burden nlmeving that he tied am build
vear
unprnfarpnmoseaf..ala>, 304 — ROUGH ELECTRICAL
01.as owner of the property.am exclusively contracting with licemed contraeon to 505 — FINAL_ ELECTRICAL_
mawcl the project(See.7044.Bu.ine..and Prufaeians Code)The Commctor's
Lures Law does not ttp,pIy to an olds or property woo hands set haps, thereon.the 507 — FINAL PLUMBING
mod who eootmat.nor send, lin.,(=n.wia,a m,mntnngsl Eman.ed entvtlaat m me
CI.,a mpapt.melrw. 508 — FINAL IIF_ClIAtJICAI_
01 am exempt sneer see. E'A r c for tris ma.ot
Owner Date
WORKER S CllMl'ENSA'1'IUN IlEC1.AItA'I'ION
I Mrthy allies under penalty of ps jury one of the follox ing declmatiotn:
❑ I have nJ will n provided
a Cby Set, of comnm m seLahsar rc de workers L/ /
C'nnlpene aril as provitled tar by section 17(111 al Ilhe Lunar Code.'for the
perhmnanee of the work for which d+is Krmit is iswad.
01 have and will maintain Worker's Compensation Imumnce,as required by Section
3700 of the LaMn Codc,far the perl'onnance of the work tint which this permit is
issued.My Worker's Culnpmoution hummice carrier a�ndL P'a/li,,.nanamer tiro
Carne,Z•Q,h:.'l'`� Policy Na.: Z I6dlL�
CERTIFicsirb s;OF EXEMPT[ON FROM WORKERS'
COMPENSATION INSURANCE
(fhissection need not he unnpleeJ it the permit is fm ora hundred dollars
(SIM)or less.)
I tenuity that in toe perfonnuncc of the work fur which this permit is issued,1 -
start oat employ any preen In any manner sen u.to became nobject ,,do,Workers'
Compsammian Laws at Califooso.Dam
Applicant
NOTICE TD APPLICANT:if.Faun n ding this Certificate of Exemption,you should
hoeamc subject m aha W akur's Compensation pnwldonde.sor the Lava CoYou moat
Q O Emhwith comply with such pmvi.ions ar this conal Oall be doenool revoked.
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