05010146 (2) CITY OF CUPERTINo
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION 'I
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT N00 50 10 14 6
OW NFR'5 NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
408 861-9545
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
loo LICENSED CONTRACTOR'S DECLARATION
m❑ 1 hereby affirm that I am liccnxd under provision or Chapter 9(commencing Job Description
�z wire Section 9003)of Division 3 of the Resincu and Professions Circle.
Amy license is ..
� =a. mmne"a, elf REPLACE FURNACE & ADD A/C'
Liccnx Claa Lica
Dam Canteannr START JOB WITHOUT PERMIT/BPERMFEE DOUBLED/
SS ARCHITi2-�5-DLCLAR ION
>WU IonAmundmyplaaehalIWuxdaspuhli ecords INVESTIGATION FEE
C
G Licensed Professional
�' g OWNER-BUILDER DECLARATION -
a$ I hereby affirm that 1 am exempt from the Contractor's License Law for the
Cr o following mason.(Section 7031.5.Business and Pmfe.tlnns Code:Any city or county
<m�+ which muddies a lanmit m ehauum,alter,imprnas,demolish,or repair any succoure
prior it)its issuance,also resiims the applicant for such permit to RIC a signed statement
=i< thit he is licensed punuantuide,provisions of the Contractor's Licenx Law(Charter 9 Sq.Ft. Floor Area Valuation
e at (commencing wi th Section 7(M)of Division 3 of the B usincsx and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of $7900
Section 9071.5 by any applicant for a permit subjects lie applicant to a civil penalty of APN Number Occupancy Type
not more than fins hundred dollars(5500).
1,a owner of the pmpeny,ser my employes with wages a their tole compensation,
will do the work,and me structure is not intended or offered for sale(Sec.7044.Business .3 ib3uu=
and Profcaioa Codc:The Contractor's License Law does nota I to an owner of RNA
tpI /� R rr �,re Inspections
own enywyo builds. rovislmpmwsdmreoganAwha does ire not such work oro offered
his IL�IIS\R //u �II. D p
howemployecs,Ding orded malsuchiotis scatents Within
intended or be owner Illi aBVftL/,Y:`\l Igl��
builder .,me have
the
or improvement is that
within ane year of completion,be owner
builder will M1ave tha burden of proving that he did not Wild or improve for purpose of
0 FEB 2005
Las owner of the progeny.am exclusively contracting with:itched enactor's to v
construct La the project(Sec.9004,Business and Dpwho bei Cade:)The Conmcton, n
Lt
cIselaw doesnotteas owner ofinemory whosedpds orant improves Caton and Y V u V
who contracts for such projects with a conmanor(s7liccnud pursuant dm Comnetors
Line
ne Law.
❑ tato exempt under See ,B6 PCfor thiamason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby afBIDI under penalty of produry one of the following declarations:
I have and will maintain a CeW firnm of Consent m elf-iaum for Worker sComper-
sation,as provided for by Section 39W of me Labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,a required by Section
of the labor Cade,for the performance of the work for which this permit is issued.
My Workc/(s C,am nsaG�tln Insu na a-mcr and Policy m ��
Cam
cc / /// ! Policy N..
CERTIFICATEOFEX MPION FROM WORKERS'
COMPENSATION INSURANCE
(This kkC itm recd not M complemd if tle permil is forone hundmd dnllaa($IMI
or leas)
1 cenify that in the perrorm ince of the work for which this permit is issued.I shall not
employ any pefson in any manner m a to become subject tot be Workeri Couramiation .
Law s of Cnlim.i..Dem
Applicant
NOTICE TO APPLICANT:if,after making this Cenificate of Exemption,you should
became subject to the Worker'3 Compsnalion provisions of the Labor Code,you most
,Z forthwith comply with such pmrisina or this permit shall W deemed¢yoked.
ZO CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency lot the perrormance of - -
1r the work for which this permit is issued(Sec.3(199.Civ.C.)
:tl Under'.Name
1• Lender's Addmxs
7 2
J 0 I cenify Nal I have read this application and sum that the¢bow initiation.is
y F correct 1 agree to comply with all city and county ordinances and state laws relating to
_„ doing construction,and hereby authoris representatives of his city to enter upon the
C ahwcmentioned property for inspection fouTues.
(We)agree to ave,indemnify
and p harmless me City of agirmsna egaial
h liobilitia,judgmcnts.eosu and xpcnusw ich they in any way accrue¢gains aid City /y '0 `
;)z in conuyucncc of the gramin of this permi. %L J
APPLICANT UNDER A DS AND W:L OMPLY WITH ALL NON-POINT Issued by: Date
50URCEREGULATI S
- Re-roofs
Signature of Apph onuanoe Data
IIA'l.ARDOUS MATERIALS DISLOSURE Type Of Roof
Will the applicant ser future building aeeupantat rc or handle hazardous mammal
a defined by the Cupeniner Municipal Codc.Chapter 9.13,and the Hcalh and Safety
'OLCOake.o0os:s53:fa3' /�LQ'�^','y All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haeodtus air contaminants as defined by dm Day Area Air Quality Management all new materials for inspection. -
uint \ _
❑Yes
:bac ma!the humrdnux materials gquimmcnu under Chapter 6.95 of the Califon.
Iia He alth 6 SafctyCod.Sc o'n2255115.259Jand 25534.Iundcrsand thmifmc Wilding
data not eurrendy haw a m ant that it u my poaihility to notify the t<cupant of the
men iremewmcnmstnme'dortaiad'canccniocamoraapancw Signature of Applicant 'Date
I �r �S All roof coverings to be Class"B"or better
Owner or authorized spent IfDam