12030058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10330 CALVERT DR CONTRACTOR:ALLIED AIRE SERVICE PERMIT NO: 12030058
INC
OWNERS NAME: ANN MANDAVILLI 470 S HILLVIEW DR DATE ISSUED:03/13/2012
OWNER'S PHONE: 4084805805 MILPITAS,CA 95035 PHONE NO:(408)934-8844
_.0 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL❑
4 OO5� INSTALL FURNACE IN SAME LOCATION
License Clns///�i�7G��//JJD� L/ilc.q �
Contractor/1/64 410" ,Qa.)/IQ Date 34-9/...7
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7(100)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 herehy affirm tinder penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Fluor Area: Valuation:$950
I have and wilI maintain Worker's Compensaion Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:37518013.00 Occupancy'Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon die above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accnte against said City in consequence of the `` 373
granting ol'this permit. Additionally,thrpplicant understands and will comply Issued by: 5.64 1/ ATl/� Date: '7?
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
2�3/� any RE-ROOFS:
Signature - / - � � Date`� , `' All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION •
Signature of Applicant: Date:
I hereby affirm that t ant exert from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I.as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044.
Business&Professions Code)
h as owner of the property,an excluvvely contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533,and 25534. I will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: Health&Safety Code.Section 25532(a)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District
performance of the work for which this permit is issued will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
Sepias I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S1°' 25505,2553 rid 25534.
Section 3700 of the Labor Code,for the erfonnnnce of the work for which this ��Z!
P Ownerorauthorizedagent: / � Date: "--*
permit is issued.
I certify that in the performance of die work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Conhpenstion provisions of the Labor Code,I must I hereby affirm that there isa construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above infomtaion is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities.judgments.
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the indicant understands and will comply
with all non-point source regulatims per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
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