04100183 (2) CITY OF CUPERTINO
BUILDING DtvTs3oN PERMIT - aCONTRACT�OO R JNFORMATION
BUILDING ADDRESS: - PERMIT NO.
A & H HEATING 04100183
OWNER'S NAME:. PERMIT ISSUE DATE. - -
AY
10NE:
SANITARY lt�tOL 10.'
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
SLOGELECT PLUMB MECH
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u00 LICENSED CONTRACTOR'S DECLARATION - -Job Dt}y{:I,[J��II 2® _ — -
ZC INmbYaffirmiMtIam licensed oars and paionsofC apter ode.s9myher(commencing ,^ - Ills Ilii II those INgm_
<b with Section]ll(M17of Division Jof NC Business and Professions Codc.end mylicenu is
. oro in Nllfua'eaade t.
5y� - License cls. — Lk.k REPLACE FURNACE & A/C
Z'G Dam _ — Cmuntem OCT7
£',j'J ARCNITECI-S CZ '2004 _..-
CC6 I understand my Plans mail he used.public accords
3 0 Liccnscd pndcssional I� II tI It ®B II -"'-
iS OWNER-BUILDER DECLARATION IVU( IIII�a/nl IILIIS Ifnllq`tJVlll � ..
F - 1 hereby alum Nal 1 am exempt men the Comraaor's License law for tar
_no following mason.($¢lion]1131.5,Business add Profusions Code:Any city or county .
K m which requires a Permit to consuueL alar.improve,demolish,or repair any swnum
prior o its issuance also requires the applicam forsuch permit to rile a signedmicmem
t�<
that he is licensed pursuant to the previsions of the Comment's License Law to.ptm 9 ... .Sq.Ft..Floor Area Valu¢ On
aFo (commencing with Section 7")of Division 3 of the Business and Professions Code)or '
y
that he is exempt IMrtfrom and the hasis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Pamir subjects the applicant a a civil penally of _ 3 V9 M.31t910 0 - Occupancy Type -
not seam man five hundred della.(SSIIDk . . 0241{'Y1asOsY' _
0 LmuwnerofimpmWny,ormyemployeawithwagmmmeirsolecompenudon.
will do the work,and me swnum is not intended oronertd farm).(See.7044,Business
and Professions Code:The Contractor's License Law does not appy to in owner of - . . Required Inspections "- -
pmpenywho Wilds or improves thimem,andwha dacmuch work himselfor through his
ownempmyees,provided that such improvements are not infrared oroRered for sale If. -"'—
however.are building orimpm eat is said within ane year of compliumn,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
.it J.
1,as owner of the Impart.ma CZcl.ivrly eodiraning wlm licensed eom.ebR in
commet the pmjca(Sec.704d,Business and Professions Code:)The Conhacmrs Li.
cense Law data not apply to an Owner of property who holds or improv Merton,and
who contracts for such projects with a contractor(s)licensed purmonto me Connector's
License Law.
0 I am exempt Linda See. .B&P C fm this mazon -"
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury am of the following declarations:
I have and will maintain a Cenifiufr of Consent to self-imum for Worker's Compeer- -- -
sation,.provided fm by Section 3700 of the tabor Code,for the perfarman¢of the
work for which this permit is isaurd.
0 I have and will maintain Worker's Compensation Insurance,az required by Section
37W me labor Code,for the performance of me work for which this Permit is issued.
Fes InSfforrm,runlm Nd Polley nam am:
C7-057
am n (ISI ll-V I N% Policy Na.: I
CERTIFICATE OF EXEMPTION FROM ERS' - — -
- -
COMPENSATIONINSUR N
Mir section need not becomplemd lithe Permit is for one hundred dollars($100)
or lona)
1 certify mm in me performance of the work for which this permit's Ismail.I shill not
employ any Person in any manner an as in become set act to the Workers COmKinso n
Laws of California.Dafr
ApplicantNOTICE TO APPLICANT:IL after making Nis Certificate of Exemption.you should - - - --—— -
become subject to use Worker's Compnumion provisions of the labor Care,you most
.J O foMwim comply with such Pmvoions or mil Fermi shall N deemed revered.
Z CONSTRUCTION LENDING AGENCY
Ihereby affirm Out mere is a commudnn lending agency for the performance of
C'7 to work for which his permit is issued(Sec.3097,Civ.C.)
Ik3 Q Undres Name
fi
Lender's Address
fJ 0 1 certify that I have mad this applicmion and sum ma the above Ofmmatiun is v
,y H correct.l agree to comply with all city and county ordinances and more laws miming to
0U building construction,and hereby authome motiamaiv ofthis city to enter upon he
ra aNvc-mentioned p.Klty for inspection puryoses
(We)agree to more.mdemnify aid keep hasmlev the City of Cupertino against /
F'rq
liabilities judgments.costs and expenses which may in any way acrneagainst said City
U Z in consequence of the Sol of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DaI -
SOURC REGULATIONS. b, 414
Re-roofs /
Sign urs of App innUComrsmor Dau
HAZARDOUS MATERIA DISCLOSURE Type of Roof -
Willtheapplicanttarfummbuildinge.c haptsacraor handle Health
mound
az defined by the Cupertino Mudici al Code.chapter 9.12,and @e Haalth and Safny
AdaLcom,Semod 255320)? All roofs shall be inspected prior to an roofing material bei. Installed.
❑res Na P P � Y g g
will the applicant or macre building Occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha'rardous air contaminants az dclincd by the Bay Area Air Quality Management all new materials for inspection.
Dissin?
❑Yea [
1havemadmeh ua ousmaterialsmquimdenmunder Chapter6.95ofthcCalifory
nix Hwlm&Safety Code,Smtiom 25X15.25533 and 25534.I un&m=d thaiflM Nilding
dors n r curandy hart a,.nam;N it is my resp mibility m netil'y the iecupam of me
myui¢ swhichmuslNmetp- ti acaraca" Signature of Applicant Dale
own nmaethoriedagent Dafr All roof coverings to be Class"B"or better