01110006 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
21404 SHANNON CT ALTON AIR CONDITIONING & HTG 01110006
OWNER'S NAME: APPLIC TION SUB DATE
MONICA LIBBY 45300 INDUSTRIAL DR 44 11(01/2001
PHONE: (510) 490-5655 SANITARY NO. CONTROL NO.
O O ARCHITEC MNGINEER: BUILDING PERMIT INFO
z w C BLDG ELECT PLUMB .CH
NZ. O F= L= L
LICENSED CONTRACTOR'S DECLARATION
6'^? Job Description
I z"n I y offrm tha l am licensed under prowtuons of Chapter 9lcommen<ing REPLACE FURNACE W�l O O U 0 0 BTU.
vtS:. vilh5e am7")of Division3 riche Business and Professions Code.and license
y Y I farce and If. / C1
z n'6 Ir lax. Lit.a r
'0 a O D m - Crams,
u O ARCHITEC 5 DECLAR -
? 1 under mad my plans shall be u.xd ox public fords
l n O O Lfxcnsed Pmfessinnul
o y OWNER BUILDER DECLARATION
,,_v, 1 hereby affirm that 1 am<xmnpl from the Comareau's License Law for the
Z afollowing reason.(Section 7031.5,Basins,and Protesions Code:Any city or county
H $3100
_
F a which requires a permit to commuter,alter,improve.demolish,or repair say stratumn3ow prior c"issuance,also requiresthpplicant for such Permit file a signed statement.
dsatle sl2 rtsedpu6uanngihep wt.ons ofthcConaannrsL Is (Cluptn9 t t �f �j'(((''��}J C' of 1 r `• w Valuation
(commencing with Section 7")of Division S of the Business a d professions Code) r.l t sx 3 ,.3 6�Z ri`:°9'•e�+x{.•: I , ,
or that he ii exempt therem froand the basis for the alleged cmumniod.Any violation �r
of Section 1031.5 by say applicant for a permit subjects the applicant to a civil penalty
of no,mate than five hundred dollar,($50(r. 3 0 5APN 149*E Occupancy Type
❑I.a.ownerofthepropary,ormyemployeeswithwagesasmdrsalecompensation, 307 INSULATION
will the'work:and he oriawte is at intended or oncred for safe(sea.law, 601 — ROOF TEI#Rgt 'Inspections:.
Business and Professions Code:The Contractor's License Law does not apply to an '
owner of property Who builds or improve,thereon,and who does such work himself 602 - ROOF PLYWOOD NAIL
or through his own employees,provided tbar such imp rmemen¢all not intended or _.--.
.offered( l If h the building imp ane t Id th bre year of �- -
completon the ,wnerhu'mer will have theburden ofpmving that held not Wildor 603 ROOF BATTENS . -
impmsefmpawse.fsah.). 604 - ROOF IN-PROGRESS
❑Las owner ofthe p(Sac.704th excBusiness dPronmgwithlicl:)T Contractor'.
License
.. I
conswct the pejo(Sec. a a Business and Professions Code;)The Contractor's ,
License Law does not rapply.suc mon owner,or popery who build,ar improves thereon, '
.and.who.mmm�x.forsuch projects.wiN.a comrxtorlsJ-licensed-pursuant.m the. _
Contractors License Law. "
t. -
_ ' 1 I" f.B&PCfar this reason
G l am exempt under Sec.
Orr r' ... D ..
WORKER'S am COMPENSATION DECLARATION F'n. 6��S E®
0 Ihereby affirm under penalty of perjury one of the following declarations: •!9
❑ I have and will maintain a Cerifvate of Conxat to self-insure for Worker's JUN 112002
Comp rrounion, as provided for by Section 37W of the Labor Code, far he
pc farrnance td the work for which this permit is issrad.
J.e and will maintain Worker's Cmulso iaran]as...a.,as requited by Section
37❑1 h of the labor Code f th perform n e -f the work f which th x perm t rs BUILD �py��/••��
-.L - M Worker,Ca a wai Invaane.c a ad Polity out req r •-• -•^----- °'^�`•�•'-^- -"
jii
Policy N (n1\ltt?i.�'S� f-- li:.,L- (f: )' _"•.L-;'Cxt, si (;'
IFICATION OF EXEMPTION FROM
.. '(Ib•isr'sttuon need nmbemPc l WORKE.R,S
mlTIOINURANCE-'-,',
_ .,a. _ __ ___--- ------ _ .___-_
%Speter —_._.
. .
(Elllnl or less) -
I certifythat nin theperformance
monthwork for which thct 1sissued,' _
'shall not employ any fe aIn it any manner so as to bcaornc sohled to the Workers
Compensation laws of Caiifomia.Dau
. Applicant-
NOTICE TO APPLICANT,If.after making this Cenificate of Ewmption;you should •
biosubject sub ect to the Worker's previsions Compensation pvisions of the Labor Code,you must
0 O forthwith enmply with such pmvi,ians or this permit shall be deemed revoked.
�'!VCONSTRUCfION LENDING AGENCY `
(••'Wti
r
that the is'a consimnro lending agency for the perfurmancc r-
of the work far whim "
h f this nit is issued(S3091:Civ,CJ
Lender's Nbmex_c,..,. ._- .... -. . ,_.,..:.. . ,,
. ,... >.-...,v.
4' A fendcrsAddresx .
nom• ,Z , ._.. ..- _. .,-... .. ...,
V-0 I unify that l have re ad this application and stmt that above information is -
fma„, cort&cl.,me to comply with.1l.city and emarty,mchuse nca and area,laws relating - --- - -----------._. - . .
mbuildingcunarucvom.and hereby outhbriee represcntatives ofthis city toenurupon
} the tr ovemomionM property for inspection purposes. . ,
F (y (We)igxe'to save;mdemvify and keep h asst the City of Cupertino against
U-VJ Iiabiliti judi ca.coso antl expenses which may in any way acerve against said
V-Z Cityy i coax nee of the gmn1mg of this pcimit.;. ' -
APP IC U ' .`(' S 'D WiLb COMPLY WITH ALL NON-VOLYr --Issued b - Date
�� — 0/
_ S JRC REG.A N" •` „O y'
I ppb v onraemr .' : aid,r Re-roofs ...
HAlARDOUS MATERIALS DISCLOSURE
W the spy wont or fit building occon,stat at. r handle harardous mvertal Type of.Roof
as de by the C.,ximm.Municipal Core,Chapter 9.12.and the H hh and Safety t
Cad Sat ore 255320e0 - t'.gx.' a }x• ' 1� `il - f 3+' :x:�i} 1.! �tJ s _ . . . _._ .
ON. _-All roofs..shall,be inspected prior to.any..roofing.material-being.installed...
!Will the pplica t or future Wilding mrapant use wapmentor devices wnch If a roof is installed without first obtaining an inspection,-I agree to remove
emit hamrdam, it x-rumairoms x d fined by the'Bay Arco AQuality Mao gement
Dist ctlall new materials for inspection.. Applicant understands_and will comply with
all non-point source regulations.
r' • I'.
1 have read the baMous materials regmremems under Chapter 6.4i;f the
C dumfd Health&Safety Code:Sections 25505,25533 and 25534.1 understand that _
ddin docs vin curemly have a tenant,that it is - 'bilis t of the -- -- - - - - -
g Y Y m re me, y,nitrify - -
curyam of rcquircm i which must be mei poor to iisuance of a Cenifcmc of
p'° Signature of Applicant Date
wn or orixd agent UUne All roof coverings to be Class"B" or.better
.. .. . .
- a( OFFICE -