09040154 CITY OF CUPERTINO
BUILDING DIVISION PENT 4r �4"SLV y� r � 1'
BUILDING ADDRESS: PERMIT NO.
10490 FLORENCE DR VALLEY HEATING
OWNER'S NAME: PERMIT ISSUE DATE
nA
SHONE: SANWA CONTROL NO.
(408) 2514-6290
ARCHTiTiCl7ENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LI p p LICENSED CON'TRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
t, with Section 70(IV)of Division 3 of the Business and Professions Code,and my license is
in ful%;A5ARcHr;i RPLC FURNC, ADD A/C 9 DUCT RUNS, RPLC DUCT WK
j ,Z LicenLamE- pateContrww
CTS DECLARATION
I understand my plans shall be used as public records
DyU
Oy Licensed Professional
rn 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y^ which requires a permit to construct,alter,improve,demolish,or repair any structure
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 Conuactor's License law(Chapter 9 Sq.Ft.Floor Area Valuation
%t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 9 O 0
i $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($5=. 32635055 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is notintended or offered for sale(Sec.7044,Business ns Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of (1 p
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.11.
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
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Caw does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I i have and will maintain a Certificate of Consent to self-insure for Workees Compen-
.tion,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
37 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees m nsation surance carrier and Policy n are:
Cartier. 'e Policy No.: /%��
CERTIFICATE OF EXEMPTION FRO WORK RS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compcnsadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Gabor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z' CONSTRUCTION LENDING AGENCY
E~.r rA I hereby affirm that there is a construction lending agency for the performance of
(x> the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Lendees Address
U 0 I certify that I have read this application and stare that the above information is
LL►" correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorize representatives of this city to enter upon the
W above-mcndoned property for inspection purposes.
a (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
U Z in consequence of the granting of this permit. Date
►-r APPLICANT UNDERS DS AND W COMPLY WITH ALL NON-POINT Issued b f:
SOURCE REGUL qS
�-
—� Re-roofsG7
Sig App' on Lor Date
AZA DOUS MATERIALS DISCLOSURE Type of',roof
Will a plican,or future building occupant store or handle hazardous material
defined y the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
E]Yes o
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future ilding occupant use equipment or devices which
-mil hazardous air contaminants cic mcd by the Bay Arca Air Quality Management all new materials for inspection.
Astrict?
❑Yes ❑Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements; metpri rtoi c�nraccrtifieatenrOceapanry. Signatul7:of Applicant Date
All roof coverings to be Class')"or better
Owner or ori a t are
�Iq r 1 5L
CITY OF CUPERTINO
4 avq-.�f
FURNACE/AC
-- £CI OF -
CUPEkTiNO PERMIT APPLICATION FORM
APN# � � �� �5` �, � Date:
Building Address: /9 FId
Owner's Name: Phone#:
r` er1cQ cam. 1� C.�� LM --r7 �- 63a2
Contractor: Phone#:
Fax#: �— P-9 q— ;1-q'1
Contractor Niense#: 5rCupertino Business License#:
Contact: Phone#:
Fax#:
Building Permit Info:
Elect [ Plumb ❑ Mech DT
Residential Commercial ❑.
Job Description:
c
For Residential Installations:
Attic ❑ 1"floor [� 2nd floor ❑
Adhere to minimum setback requirement 0�
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
9 ) "'206
Strapped 0 On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation:
Green BuildMust attach Green Building Ct eck list to this application