03080017 CITY OF CUPER'I'INO
I BUILDING DIVISION PERMIT CONTRACTOR INURMATION
a BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO03 0 8 0 017
i
OWNER'S NAME: 10570 S DEANZA BLVD PERMIT LSSUEDATE
dft MATT THOMAS 2003
ONE: (408) 861-9545 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION IobDescription
(�F I hereby affirm the,1 am licensed under pmvixi ims of Chapter 9(commencing
a� with Section 7000)nf Division Sof OO Business antl Pmfcasium Codc,and my lice..is
mmBmreaande 5 REPLACE FURNACE/ADD A/C
j Licari.CI Uc.N
Do,d Cumncmr_i
e2 R HITECTS DECLARAT3Bf
` 1 un wand plans shit W used as public me
> U
10� Licensed Pnscssittal
OWNER-BUILDER DECLARATION
2 1 hereby affirm that I am exempt from the Contractors License Law rot tW
$ following rtmnn..(Section 7031.5,Business and Profusions Code:Any city or county
which requires a permit to construct,alter.improve,demolish,or repair any structure Cj 8
ZLn pilar In its issuance,also requires the applicant for such Permit u rile a signed suumcnt
N2 < thatWislicdn.spanuanunlWprovisionsoftheContrseur'sLiceme aw(chapter 9 Sq. Ft. Floor Area Valuation
3 $ (commencing with Section 7000)Of Division 3ofthe B.sinesxandProruelna,Cdo).r 3S61OO92 . 00
Ijlxt he u exempt therefrom and du basis for the alleged exemption.Any violation of
Section 7031.5 by any oppliunt for a permit ubjects the applicant o a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(6500).
p I,a inner of the pmWny,or my employcu with w SCS M theb sole compensation,
will do the work and tha auoctum isnotinunded aroRertd fond.(Su.7044,Buinw
anproperty who d Professions Code:The Con racmrs Liceve taw dais not apply w an owner of 303 — ROUGH ft"PowMODS
builds or improves thereon,and who does such work himmiror through his lm
own employees,provided Nat such improvements are not intended oraRered Resume.If. .304 — ROUGH ELECTRICAL
however,Ne building or impre.n.,is said within one year of completion.Ne owner.
builder will have the burden of proving that be did not Wild or improve for purpose or 505 - FINAL ELECTRICAL
"le') 507 - FINAL PLUMBING
❑1,ea owner of the rompeny,am exclusively contracting with licensed cunuacwra to 508 - FINAL MECHANI CAL
construct the project(Sec.70th,Business and Professions Cade:)The Cemkamars Li.
come law does not apply to an owner of progeny who Wilds or improves Ihe¢on,and
who contracts for such projects with a eon ractaKs)licensed pursuant to the ContracwM1
License Law. --- '-
lamLaemptundergee. ,B&PCfor Nis recon - • p
Owner Date
-- 1. R
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dedvatiom:
I banned will maintains CmIf .wof Consentlomir-inure for booker's Compere
cation,u provided for by Section 37W of the labor Code.for Ne performanu of the r
far which this permit is issued. '-
1 bout and will maintain Workers Compensation Wurance,ss rumored by Suction
00 of Oc LeWr Code,for IW performance of the work for which this permit is issued.
Or,
Compenel don Insurance cirrimand Policy num ram'
Cartier. Policy No.: 1 ,
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(This it.reed not W completed if,he perms,Is faone hundred dollars(51011) ,
or less.)
1 certify that In the performance of the work for which this permit is heads.I shall not
employ any person in any manner an u w become subjacuo the Workees Compeneafion
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If.after making this CCnIECald of Exemption,you should
WCOme Subject a the Worker's Compeesatian provisions of the Iahry Che,you mus,
=Z forthwith comply with such poMsi...or this porniuAall W dumdd rovnked.
zCONSTRUCTION LENDING AGENCY
I Wroby affirm that there is a constriction lending agency for the performance of
x the work fur which this permit is issued(See.3097,Civ.C.)
12 Q Leadm's Name
Z lender's Address
J p 1 certify that I have read this application am suss that the above information is
y correct,I agree to comply with all city and county ordinances and time laws relating to
building caiconed re and he authin rcpreunml,m of this city to enter upon esu
a abovemcn,iuned progeny fa mpcNon purposes.
(Wc)agme,.save it in ly harmless @c City of Cuperoom against
tib liabllitles,Jutlgmcnts.c anti cx swhic ay in anywayeccroc egeimtaid City f�J•..��
J Z APPLIon CANT oft E rTrng A,pe ILL. OMPLY WITH A N POINT Issuoamed by: Date ,✓ 6
SOURCER LAg�
l� Re-roofs
ature of Ap VCommc Data
HAZARDO ERIALS DISCLOSURE Type of Roof
Will pplicant or fuwm (ding Occupant Stare or handl hamOdmis material
u defined the Cupertino Mu IPA]Cock.Chapter 9.12.and the Health and Safety
ale.Section 25532(an All roofs shall be inspected nor to an roofing material bei. Installed.
ED Yet NO P P Y 8 8
Will One applicant orCut Wilding occupant use equipment ardevious which If a roof is installed without first obtaining an inspection,I agree to remove
It h'embou air contaminants at, d by thc Bey Arca Air Quality Management all new materials for inspection.
inricR
❑Yes N
I have read the hasallo =,it myuimmenu under Chapter 6.95 of tht Glifnr•
ria Hcalth&Sefcty ,SaGons3 .25533md25534,lunwm=dthuifthe Wilding
darn nal cunendy Iis voa knant ' my respa umbility m nndl'y Iles upout of the
tmm
rcyucnu - glom wulm .a.r.Ccnificateo Signature of Applicant Date
wnerar iaedasem a.� All roof coverings to be Class "B" or better
Ei��zml agent