01100055 (2) CITY OF CUPERTINO
BUILDING DMSION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0,
10104 CONGRESS PL SUPREME AIR SYSTEMS 01100055
OWNER'S NAME: APPLICATION SUB DATE
EVERETT KAREN E 520 MCGLINCEY LANE #15 10/09/2001
ONE: (408) 879-0334 SANITARY NO. CONTROL NO.
n-ZO ARCHITECTfENGINEER: BUILDING PERMIT INFO
m_ BLDG ELECT PLUMB MECH
a LJ IJ C-7 L_.I
mz LICENSED CONTRACTOR'S DECLARATION Job Description
5z_C 1 hereby affirm Nm I am licensed under provisions of Chapter 9(commencing p
wF_u with Section 7IX10)of Division 3oftheButimellmmdPmfcssiom a< d 'lose REPLACE FURNACE & ADD A/C.
C x I- is in full farce and efRmy �1 / n
a¢< License Class (t li Lic.' l9 FINIALED
'O a O Date Commcmr
3 u.u. AR 1 DECIA
Ural rand my plan.,,all be used as Public records
JUN 0 4 2002
S in O Limned Professional
in. OWNER-BUILDER DECLARATION
h 1 hereby affirm that I am exempt from the Comment's License Law for tha
z�0 whitfollowing (Seco 70313 Business mp improve,
de Professions Cade My city or wunry BUILDING $4700
whmh ts permits .wt Itr.imfr suchmohsh orrerour.iloseysvucwre
a3- =its ned Inusorcq teem appl can for suchp &.Lt1. ..Law s fa m• ,�g,,y-,�� �p,�.
dot he cwith c,i.O7ualf,to hprovisionsof Ne the Blmors ad PolawmisCd') �3�`Q,Fa ffl gr.pagB,a( ;y Valuation
(commencing,rn Sect 7IXpofhe - isoof the Bp;ih clandibn An,ACade) (1{j'1y 13 ,17 Y"7, lY Cll,s..r.^ ai':• .
of thin io rs exempt therefrom and the bass for the alleged cdethant to Any v Pearson
of Season]703 I�than iv any applicant fora permit subjects me applicant m a civil penalty
afoot more than five hundred lancers(Seon) 1 Q g°fPN & WATER Occupancy Type
❑I.as owner ofthe pmetry.or my employees with wages as their sole compensation, 202 _ UNDERFLOOR PT, IMBING
will do the work:and the immune isnot intended or offend fat sale(See.'/ .
Business and Professions Cade:The Commie m's License law does not apply to an 301 - ROUGH PE14OR04&pections
owner of property Who Wilds or improvas thereon,and who does such work himself
or through his own employers.Provided that such improvements tae no,intended or 302 - TUB & OR SHOWER
offered far sale.If,however. he budding or improvement is sold whom arm year or - 5 02 - FINAL PLUMBING ENERGY
he owner-Wilder will have the burden°f proving that he did not build or
completion,fire
506 - GAS TEST
gwi 507 - FINAL PLUMBING-
dl.as owner In the property,am endueWdy contracting With licensed Cometoa m
License
the project(Sec.Ito a OwnBuser of
and Professions Code:)The improves
tmaore,
and who
law does not apply tom owner of property who Wilds se impmvu thereon, 1
and who comma¢far such projects with a commemrts)licensed pursuant to the -
ContrectMs License law.
_ O l am exempt under Sec. ,Big:P C for this reason •ii m,,
O!o. Date
WORKER'S COMPENSATION DECLARATION
%of
ereby affirm under penalty of perjury one Of the following dalanEonx:
end will maintain a CcrtiGcam or Consent m self-insert for Worker's
tion, as provided for by Section 3700 of the labor Codc, for the
of the work far which this Permit is issued.
nd will maintain Worker C......in.Insurance,u required by Section
e labor Code fo th perfamorme of the workf M1chmpernutsre
i s Compe sat mance tamer and Pol ry herL6 am
CATION OF EXEMPTION FROM BKERSC ION INSURANCE •Imed if the pmnit is fm arm hundmA BoomscsaJ
I certify that the peAamrm ce of the work far which this permit is isau ni'I - - - `•'- .. ..
shall not employ any person in any manner sa as of broom,subject to the Workers' '
Compensation Laws of California,Dam '1�
"Applicant f-
'NOTICETOAPPLICANT:If.after making the Cenificae of Exemption,you should '
,Z became subject o the Worker's Compensation pmvisiomu of Be labor Code,you must
zforthwith comply with such provisions of this permit shell be dc,med evoked. ,
F'> .." `f"•'CONSTRUCRONLENDING AGENCY
rat 1 rkfarereby which that there is s,sued se, lending agency for the pvfomuna t '
rat of the wink for which this permit is issued(Sec 3097:Civ.C.)
r :
•
:D Q UnLinder',Name ' _
.7. ,z Lender's Addms . . " . .. .. ..
V.0 1 certify Nat I have end this application and state that the above information is
Q.0 [� emdct.1 agree to comply with all city and county ordinances and state laws relating
V a building communion,and herby euthorie representatives of this city to afar upon
'm ryI the abav-mentioned property for inspection purposes.•
E. A. (mull ogee to save,indemnify tae kap huMess the City of Cupertino against
V) Citt itic - gmene,costs and expenses which may in army way acme against said
V ► CiryJ' c equcfce of the granting of this penal,.
YPLL NT UN AN DS AND WILL COMPLY WITH ALL NON+POINT
0 F RF.GU " Pigs.1/ 1 .. i /0S o ( Issued by: y4 4 Date
art ornveyr,nDate' ' ,'. Re-roofs /
HAZARDOUS RIDOUS MATEAIS DISCLOSURE te
._ Wlbyt applicant or firrMunicipal
uni ipalCoe.Chapter 9,store 12,hmWle lmerardaua metenal - Type Of Roof
az deTned io m Cupamno Mumc pal Cody.ChePter 9 12 and the Health and Safety
Cade Section 25532(e)7 ;.•s, iDylas
s ; i'q s : ♦. .
All roofs shall be inspected pnor to any,roofing material being installed.
Will the appleam fqm Wilding«,p nt use equip t o a vee:which If a roof is installed without first obtaining an inspection;I'agree'to7emove
emit hazardous air contaminants as defined by the Bay Ala Ai Quality Management
Diatd,n
o Yea ON. all new pp
materials for inspection. Applicant understands and will comply with
all non-point source reglations.
1 have read the'harsrdons materials mquimmcns'underrChapta X6.95 of me
Califomie Heah &Safer c,Sections 25505.25533 and 8534.I understand that
if me builds s ureI have a tenant.that it is my responsibility to notify the
cups a rein' mens mh must be met prior to issuance of a Cenificae of ..
n Signature of Applicant Date _
"'" °°'"°^rel agent„ Data, All roof coverings to be Class"B"or better '
. - OFFICE "