08050056uoz
0
qU
� 74
Z
g�G
;qU
yobAy
'c cco
Z_t
CITY OF CUPERTINO�s�s,�
BUILDING DIVISION PERNHT
BUILDING ADDRESS:
PERMIT NO.
10989 N WOLFE RD
BAY AIR SYSTEMS
OWNER'S NAME:
PEIi1,11T ISSUE DATE
8
PHONE:
- CONTROL NO.
(925) 356-3000
ARCHTIECT/F1'iGINEER:
BUILDING PERMrrINFo
BLDC ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
i hereby afrr,n that I am licensed under provisions of Chapter 9 (Commencing
with Section 7000) of Division 3 of the Business and ProfessionsCode, and my license is
in full force and effect_ d_ O
INSTALLATION OF NEW SPLIT HEATING AND AIR
LiceDatense
/13 g g Contractor actof
CONDITIONING SYSTEM ( PER PLANS)
�/12
ARCHI'IMM DECLARATI
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any structum
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors Ucease Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
11614
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number Occupancy T
P y Type
not mom than e hundred dollars (M).
five
31605051 . 0 2
[11, as owner of the property, or my employees with wages u their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractors License Law it= not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or Improve for purpose of
salt.).
❑ L as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contraemr's Li -
cease Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractors) licensed pursuant to the Convectors
License Law.
❑ 1 am exempt under Sec B R P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
-
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
satfon, as provided for by Section 3700 of dra Labor Code, for the performance of the
work for which this permir is issued.
❑ I have and will maintain Worlmrs Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
'
My Workers Compensation Insurance carrier and Policy nuum� b r are: t� P-
G07
Cartier e0ieiiA 11*tST PolicyNo.: ` 00_ f' I3
CER Flit CATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed lithe permit is for one hundred dollars (S 100)
or less.)
I certify that in the performanca of the work for which this permit is issued, I shall am
employ any person in any mannerso as to become subject to the Wortmre Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of do Labor Cade, you must
'forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a construction lending agency for the performance of
the work for which this permit is Issued (Sec 3097, Civ. C.)
-
LandcrsNamc
,
Lender's Address
I certify that I have read this application and state that the above information is
'
conett 1 agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-merttiaKd property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, Judgments. costs and expenses which may in any way accrue against said City
In consequence of the granting of this permit.
APPCE UNDE, TAI�D� AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURGULA>]SU
�� Z a
Sign of Appliartr/Contractor f Dart
Re -roofs /
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code. Cliaptef 9.12. and the Health and Safety
Co le, Beetles 25532(a)?
❑ Yee
All roofs shall be inspected prior to any roofing material being installed.
,$�70
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Safely Cade, Sections 5. 33 aril 25534.1 understand that If the building
does not c rally, haft a t' y responsibility to notify the occupant of the
rcgmrenxn whichm u Ora CmikatcofOccu
6�
Signature of Applicant Date
c / Z// z
All roof coverings to be Class " '' or better
g �
O tt or wthorizrA agent Date
-