05010003 (2) oL[su�ocopERON
BUILDING PERMIT �OrNTR .CTOINN .. ORMATION
BUILDING ADDRESS: A PERFECT CLIMATE P�2MRN005010003
10521 N BLANEY AV
OWNER'S NAME: PERMIT LSUE DATE
GLORIA DROSCO 10570 S DEANZ
NE: SANITARY NO. CONTROL N0.
(408) 861-9545
ARCHI]EC(ENGINEER: a BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
,',00 LICENSED CONTRACTOR'S DECLARATION Job DBSCrIpI100
m I homily idiom shat 1 am IicerlsM under pmvi sof CMpur 9(commencing
iW wiN$cction]IX107 of Diviaion3of NC Buurcss a06P 'um andmYlittrtseis -
nmly�rdyk A�wyplmx
FURNACE REPLACEMENT .
^ i Lic, l.ic.N
nt, Dale CTS DEC RA4o: wused u pis lieec _
JaU
Licensed Professional .
5 OWNER-BUILDER DECLARATION
a ' DECON
1 ha .(firm Nal 1 mcmde Contractor's s License Lew for the
ofollowing mason.(Section] I.S.Business and Professions Code Any city ocounty
Km wwhich .iti . ueve,dcares
cture
m-m ionic to its icamoun,elau mquirm thcappitmot fmsuch permitw file asigncd stateroom
that W is licensed pursuant o Ne provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area ValuaiEO
5FG (commencing with Section 7")of Division 3 of the Business and Professions Code)or - _ - -- -
'a $ that he is exempt tMmtrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Family Of 3 e 0 .- Occupancy Type---- -- —
nm mom Nan fisc hundred dollam(S500). aa
❑I,uowner of Ne Propcny,or mY employcu with waguu Nab seta compensation, n
willdo thewoh.end Neswnurt unit inundedmaRcrtA finale(Sa.]O4a,Businm aa ^&.L. Required Inspections
and Professions Code:The Contractors Littme law does not apply to an manes,Of
Y q p
property who builds or improves thereon,andwho do tsmetwork himselfor through his '
own employees,pmvfded that such improvements arc nstimandd or offeree forsale.If, �� 2005
however.the building or improvement is sold within am)cu of completion,the owner- FEB
buildve er will haNe burden of proving Nat he did at Wild or improve for purpose of r C ,
axle.). p� a¢�
0 I,as owner of Ne propene am udusively contusing with lic,m of Comanche.in p (f t R // —
conmvet the is not(gee.o an Owner
of and Professions dCodes)The s themon, nd - �� �p }I a [[v�UjJ
Li-
came Law,fou not apply to m owner of proper(who Wilda or improves Contra,and. V -
Lic"antmcu for such projects with a contractor(s)Iiunxtl pursuant m NC Convectors
x Law
0Iem exempt undo Sec. .B&PCfar this reason
Owner Data -
WORKER'SCOMPENSATIONDECLARATION -
1 thereby affnm under penalty of perjury one of the following decimations:
I ban and will maintain a Cuuficale of Canxnuo self-insure for Wmkera Compere
sstiun,u provided for by Sanson 37M of the labor Code,for the performame of de
work for which Nis permit is issued.
I have and will maintain Worker's Compensation Insurance,u required by Section
37W of the labor Code.for the performance of me work for which this permit is issued. -
y m1k s/Cf o vents jan In nett easier and Policy number am: C - - -
er. /1' - lC Polus.:��
CERTIFICATE OF fEMPI1D FROM WORKERS'
COMPE SATION INSURANCE
(This section need not W completed if the permit is forone hundred dellas(SIM)
or less.)
I certify Nat in de polom arm,of the work for which this permit is issued I shall not
employ any pass.in any manner se u to Wcome subjectm tM Workers Compcnsauon
Laws of California.Data
Applicant
NOTICE TO APPLICAT:If,after making this CariReate of Exemption.You should
become subject in the Worker's Compensation previsions of me labor Code,you most
.JZ fOMWllh comply wit such provisions or this Permit shell W deemed evoked.
zO CONSTRUCTION LENDING AGENCY
'r. 1 hereby affirm that them is a c namodon lending agency for Ne I irforrnance of
[C,> to work for which this permit is issued(Sec.3BB7,Co,C.)
QLender's Name
] z lender's Address i'•�
V 0 1 certify Nat I have read this application and state Net Ne above information is
U. F correct.I agree to comply with all city and county ordinances and state laws elating to
0O building cemtruction.and WrabyauNonm e.......i..fflintily m cnerupon the
} ahov,-mentioned prop,ny for inspcmien Panaceas, s
(We)agree to arc,indemnify and keep harmless ova City of Cupertino against
F'r4ji liabilitiu.judgmcnss.ensu anile which maysn
any way accrue agatnsteaid City
(,)Z
M��
mung 'mas it.ST3 S ANO WILL COMPLY Wl_ NON-POINT Issued by: Date
� NS. 1 3 OS Re-roofs
Signature or ApplicanVContsacmr ate
HAZARDOUS MAT RIALS DISCLOSURE Type of Roof
Will On applicant ter future builds goccupanssmrc or handle huardous material
an defined by Ne Cupertino mcipal ode.Chapter 9.12,and the Health and Safety
ode,Section 25533(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the appfiun (mute building ottupml use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit ha ardous air cones nants as d,Bned by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nu
Ilowmadthehva ousmauna mmenu under Chapter 6.95 of tW Cantor,
nu Hmlon&Safety Cade, vom3550,35533end 25530.1 or
this iron,Wilding
dos trot, randy e a .ant.that it my mipomihility b comfy tW upant of IW
mr, l,wh e`� sman .acemficateol"Ce Signature of Applicant Date
✓ as
Owner or somoda<d apcm Dat, All roof coverings to be Class"B"or better