04010039 CITY OF CUPERTINO ' ,�•
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: CAL-AIR INC 1111IT'904010039
NER'S NAME: - PERMU ISSUE DATE
ONE: - - SANITARY N0, CONTROL NO.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
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u00 LICENSED CONTRACT'OR'S DECLARATION Job Description
u❑ 1 hereby affirm that I am licensed anile,provisions of Chapter 9(commencing P
ZW with Scclion )uf Divluon3of the evsincssa d mrossum.,Codn,mdmyliccnacia
<< in full force a f c
aqi uecn cl E e ue.g 1� 115t' TI--SPIH SYSTEM/DRAINS/
E~' Da Contractor
ee ARCHITECTS DE A ATIO
g 1 understand my plans shall he used es pts mcnrds FEB 1 0 2004
JIU
;0y Licensed Professional
i<S OWNER-BUILDER DECLARATION
2 1 botchy affirm that 1 am exempt from the Contractors License Law for the BUILD'N
00 fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county
K S f which requires a permit to construct,alter,improve,demolish,or repair any structure
yZ< prior in its issuance.also requires the applicant forsuch permit to rile a signed statement
ESG That he I.licensual pursuant It)the pmvisions or the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
zea (commencing with Section 7")id Division 3 of the Business and Proflexa nee Code)or
e�. that he is exempt Ncmfrom and the Buis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
nut more Nan five hundred dollars(1500). 3i44TOOD*qrOO Occupancy Type
❑1,as owner of the properly,or my employees with wags,u their sale compensation,
will do the work,and On someone is not intended or offered for sale(Sec.7W,Business
and Profusions Cade:The Conuaclori Liana Law docs not apply m an owner of Required Inspections
property who builds or improves thereon.and who does such work himself or through his
own employees,provided Nat such improvements are not intended or offered for sale.If.
however,the building or impvemam is sold within ane year of completion;the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of she property,am exclusively contracting with licensed contractors to
consumer the project(See.7044,Business and Poofessions Code:)The Contracen''s Li.
cons,Law docs not apply to an owner of property who builds or undomi theman,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
Liccnu Law.
❑I am exempt under Sec. .B&P C for this reason
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Fri of perjury one of the following declanrims:
El 1 have and will maintain a Cenifica¢or consent to self-lasum for Worker's Compen-
sation,as provided for by Section 3700 or Ne Labor Code,for the performance of the
work for which this permit is issued. -
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performarec of the work for which this permit is issued. '
My Work.' C—ompJensati,,on Mammon career and Policy number am:
C 'e % ;!: Policy No.:-17 tXi`t Xt{Lb_
CERTIFICATE OF EXEMPTIONF WORKERS'
COMPENSATION( N E
(This section need not be completed if the Permit is for one hundred dollen I$IM)
lar lust
1 certify Nat in the performance of the work for which this permit Is issued,1 shall net
employ any person in any manner an as he become subject to the Warkers'Compensadon
Laws of CaliroMa.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ceniricale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.JO forthwith comply with such provisions o,this Permit shall be deemed revoked.
Z 01 CONSTRUCTION LENDING AGENCY
rN
W (for hoRrm that Nerc issued( ce.3 7.Clending agency for the performance of
C Fes„ Ne work for which this permit is issued(Sec.309].Civ.CJ
Lgl Q Lender's Name
Z'
z Lender's Addreas .
U Q 1 unify Nat I have read this application and sate that Ne show information is
W correct.I agree to comply with all city and county ordinances and slate laws relating to
U building construction,and hereby authorize reprcuuatives of Nis city to enter upon the
W shove-mentioned property for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
ray h
liabilities,judgments.casts and expenses which may in my way accrue against mid City
til Z in consequence of the granting of this Permit.
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL POINT Issued by: Date
SO CE ATIONS.
Re-roofs
rgnemre o(A li motor
HAZARDOUS ATER SURE °te Type of Roof
Will the applicant or future b uccupanumrc orhandIn hazardous material
as defined by Ne Cupertino Mum.pal,Code.Chapter 9.12,add the Health and Safety
Endo,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or Not building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamrdnua air contaminants m J by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have real the hanrdous materials mquirommus under Chapter 6.95 of t c Cali for.
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a mnart,Our it 0 my msponsihility m door,the aeupart of do
requimntmus as rbc met Poor to ismance of.Ccnific or Oecuu . Signature of Applicant Date
owne or oma en-- o,m2/ All roof coverings to be Class "B" or better