04090258 CITY OF CUPERTINO •_ ? `'�` y`A
BUILDING DIVISION PERMIT WON------WFO'R INFURMA.TIQN�`' -
BUILDING ADDRESS: SAN JOSE AIR CONDITIONING PERMIT NOD4090258
I_Q921 MAXTNR AIT
OWNER'S NAME: PERMIT ISSUE DATE
GILBERT W
NE: . . SANITARY NO. -' CONTROL NO.
8 2
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
till' LICENSED CONTRACTOR'S DECLARATION
x"'C I brachy affirm f.I am licensed under provisions or chapter 9(commancing Job Description
$ UU6 with Sc d 7")afO'visian Sof Ne Buses ePmfc 'oro Code andmylicanm i,
vlmree'm REPALCE FURNACE & ADD A/C W/ 8 DUCTS
i�? Licenm Lk.d
Cuntr
DECLARATION 4 A CHDECTS ARATI
W
/�U L understand my plans shall he use0 u m
public cords
tae C;iS
d Professional
OWNER-BUILDER DECLARATION
F I hereby affirm that I am exempt from Ne Contractors License Law for the
O O following mason.(Section 7031.5.Business and Pmfasiom Code:Any city or county
x m which requires a permit m construct,atm,.improve,demolish.or repair any swcture
m�'^ prior In its issuance,also requires the applicant for such Permit to file a signed statement
that he is lutmed pursuant to me provisions of thc Contmcturi License Law(chapter 9 Sq.Ft.Floor Area Valuation
(cmnmcnang with Section 7000)of Division 3 of the Business and Professions Castle)at
$ that he is exempt therefrom and Irk basis for tion alleged exemption.Any violation of
Schon 7031.5 by any applicant for a permit subjects dm applicant to a civil Penalty of 3 2lM2`1 d9(:r0 0 Occupancy Type
nm more than Eve hundred dollars(SS(p} Pane Y YP
1,u owner of Ne pmpmy,or my employes with wage u their sole rompenmdon,
will do the work,and dee structure is no.idunded or offered forsam(Sec.7044.Business
and Professions Code:The Conuactor's Lianee Law does..I apply to an owner of }p`E n5 ectlons
property who builds or barroom beacon,andwho doessuchwofkhmoselfor through his HNP
�I P
own emph,ces.provided Nauuch imprmementa artn.I intended or offered for Sla lL �\16L
however.the Wilding or improvement is sold within one year of completion,the oweer-
Wildrr will have the When of proving that he did cot Wild or improve for partner of
=ata.'. FEB L 2005
❑L u owmr of ct Sec.7pmpan,,B sinessivalynd Reductions with licensed)Theon"cumss i-
ceme La dproject(Sec.n an Business and Professions Cade:)Thees thacmfs rad
cense Law docs not apply ta an owner of property who Wilds ra improves Comon,end ®�
whocontractsLa .for such pmjccu with aconuacmr(s)liccnudpursuant to the Conuactars
License law. '
❑ IamexemDtunder See .B&PCforthisrasun
NG
owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of me following declarations:
I have and will maintain aCer iBcate of Consent to self-insure for WorkersCompen-
sauon,S provided for by Section 37M of don labor Cod,for the pufarrunco of me
wo k for which this permit is issued.
I have and will maintain Workces ComPensauOn Iruurance,as required by Schon
700 of tW La W,Cade.for the performance of the work for which this permit u issued.
My Worker f cope Sado psumnce remand Pnlirynumberart:
Cartier. Polity No.: `
iI2Io
CER 1^IC T F f MI'DONFROM WORf:ERS' �
COMPENSATION INSURANCE i
(Thu section peednothccompleud if.lm Permit is foranc hundred dollars(5100)
or less.)
I certify that in thO performance of the work for which this Permit is issued,I shall not
employ any pcwn in any manners ta bjecuo the Workers Compensation
Laws of California.Data—
Applicant t
NOTICE TO APPLICANT:If,afmf ma sing this Certificate of Eacmption,you should
become subject to the Worker'x Compensation provisions of She Labor Coda you must
.J O rOMwim comply with such provisions or this Permit shall be dermad revoked.
'Py CONSTRUCTION LENDING AGENCY
PI hereby affirm that mere is a construction lending agcory for dm performance of
a> ted work For which this permit is issued(Sec.3097,Co.C.)
W� Q Lenders Name
z fenders Address
U C) I certify that 1 have read Ws application and sum that the above information is
II, correcL I agree ta comply with all city and county ordinances and sum laws relating to
0V Wilding consuunion,and hereby aumofime ropesenutives of this city m enter upon the
ehovcmenuonW property for inspection purpose,.
F y (We)agree to save,indemnify and keep harmless me City of Cupertino against
rp Ilabilities,judgments,casts and expenses which may in any.,.cc.against Sid City
f,J z in eormsequence of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date :d
SOURCE REGULATIONS. 34tarll
Signature of ADDIicStData Re-roofs
HAZARDOUS
US MATER occupant
mor handle
Type of Roof
Will ter applicant or forum Wilding occupant Wore or handle Health and
Code.deMcO by me Cupertino Municipal COM,Chapmr 9.11,and me HcaIN Sd Safety
sc❑cties zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes No
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant o fuwrt building acoupam tax equipment ars devices which P
it horemnua air contaminants ss&rioad by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycs
IhavcreadthehvaN smamrialsmquim=nuundcrChapmr6.95ofmcCalifor-
isHcalm&safely Codc,Scc 25305.15533wd253d.lundcrsundmatifmc Wilding
does not ctm cmll aw a tuna Nat it is my mspomihility m notify me mcupmt of c ,
rtquiremc h. m takssuanaaaf.cemi mo(OcaE y. SlgnatureofApplicant Date
I v
Owner I .e I tam All roof coverings to be Class"B"or better