05020058 t,o!",,ER'S
� �a �F ' %0BUILDING DIVISION PERMIT' TQRNp,DING ADDRESS: CAL-AIR INC "''EMITN'65020058
��FRTTT.T.q WAV
NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
ITEC(ENGINEER: BUILDING PERMIT INFO
BL ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION ti
i
Job Description
1 lereby"Ma Nat 1 w lice. under pmvixdmA of Chapser 9(tommmming Jo ;
wiNSecOce7")of DiA4on]afdx Butire PmfeWom Code,Wmylicer is o '+�. ,/
in full in=and eUecs i \ter fel
5'qz Lmensc 0. Less /gS REPLACE HVAC (2 UNITS)
Z Dam —f contractor •1
ARCHITECTS DECLARATION - �r 11 � �gn
',� 1 undersexed my plum mall be used u public records
6
x.c Licensed Professional
x. OWNER-BUILDER DECLARATION �� r
iS:0 0 I hereby Maso alrmm(Section n I am exempt from the Cssium o Licence taw for IW ( �
i D o following mama. ermit7031.3,Business and ow,dem ns Cade:Anycity or county
x�$ which its isa n permit ro cnnWuct..l¢5 Improse,h Permit t ore a sig any Nuctun
prof m its censedn,aimrsu inquires thoaisim s o far such Permit Licansto and seaa mem
< thearrommi g,with
Purwant 70044 pro visions of Na,Conmcmhiicenselaons Codi)at Sq.Ft.Floor Area Va UatlOp"'`
$ (cmn a Is axe with Salion 70nd! basis f r of the Business prion. v y vi Cade)of
'hatSu a ts 31.3 b thenrrom and far
assts fns be Alleged arsnpnt w Any violadce of
Section 7071.3 by arty applicant r(a permit wbjeeu Um Applicant m•dull penalty of 3 5MNI@T4&r0 0 Occupancy Type
net mart than five hundred dollen(5500).
0 1,As owner of Elle property,or my employees with wages As their sole compensation,
will do the wark,.nd stomachic un at intended in offend for safe 7044.Bwamu Required Inspections
.M Professions Code;The Contsacmn eYm License Iaw donot apply m an awou of q P
property who builds or improves themon,and who docs such work himself or through his
own employes,provided that such Improvements art not intended are@rad formic.If,
however,the building or improvement I.sold within am year of completion.the owner,
builder will have the Wrdan of proving that he did not build or impmse for purpose of
sale.).
0 1,As owner of the property am exclusively contracting with licensed coaactan An
construct the project(Sec.7044.Baines and Profession Code:)The Cootr.ctofs Lt.
cense Law does not apply in an owner of property who Wilds or Infamies;Mercer,and
;37W
ntacts for such projects WN a eamaemr(s)Rare dpuraantmthe Ccetr el
Law.
exempt under See ,B B P C for this reason
Data
WORKERS COMPEN5ATIONDECLARATION
1 hereby affirm under penalty of perjury om or the fallowing decimations:
ve and will maintain Acam ftcaaaf consent to self-M.Me for workees conapen.
u provldW for by Sudun 7700 of the labor Code,for the performance of the
r which this permit is issued.
le and will maintain Worker's Compen ation Imunnce,as required by Section
the Labor Code,fes the performaa c of the work for which this permit u issued.
My wor/iae,..ac.a�maracas dos Iwmens:anis and Policy oumher see:
C.Mers090&r060A`su-4JLh PolicyNa.: WC 348/i9(011s'
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tits source reed not W complesed if IW peep Is fm0M hundfeddollua(g1IX11
or team.)
1 certify Not in the perfaaance of the work for which this Permit is issucd,I shall not
employ any person in any mannerm As m become subject to the Workers:Compensation
Laws of California.Data
APplicani
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject An the Workers Compensation provisions of the Labor Code,you muss
Oforthwith comply with each provisions or this Permit shall W doomed revoked.
CONSTRUCTION LENDING AGENCY
[-r► 1 lmreby alarm"ft.is•construction lending agency for the Performamx of
a> the work for which this permit is issued(Sex.709'1,Civ.C.)
aQ Lenderi Name
P z Lender's Address
U Q 1 unify that 1 have read this application and mm that the above information is
IL,P coact.I agree m comply with all city and county onlinmm and mute laws mining m
DU building construction,and hereby amholer representatives of Nis city to enter upon the
LP7 above-mentioned properly for inspection pugwms.
S (We).yme to save,indemnify and temp harmless the City of Cupertino against
W liabilities,judgments,case and eapenaa which may in My way Scene aglaiL said City
in consequence of
U 4
APPLICANT UNNERSTANe Swung of DS A1 mah.
IN WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR TON .
Re-roofs
life aof ppli Con or Data,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the Applicant or future Wilding OecuPULIMM or handle hanMaw mamriat
dcared by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
Cadc.Soedea 25572(x)7
❑Yat �tqu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipMae I or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hrssrdaus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Inset? //
OYet (3Nu
I hive rear the hism doer mamriah requimmeas underCbpmr 695 of de Califaf-
niaHalth&Satiny Cade.Secmces 25703. 377 and 25!)4.1 undcntand thuif Na,Wining
data cot cuandy hon a Mo Nu It' y responsibility An notify Ne occupant of de
regdmmcntsw mer same of a Continue of Occupancy. Signature of Applicant Date
3/S1JS All roof coverings to be Class"B"or better
Owner at amharimd agent Dom