09060158 CITY OF CUPERTINO
BUjLDING DIVISION
PERMIT � 0
BUILDING ADDRESS: PERMIT NO.
PERMIT ISSUE DATE
`WNER'S NAME: CONDITIONING
S A
CONTROL NO.
408 29:1-4717
BUILDING PERMIT INFO
ARCHrrEC'r/ENGINEER: BLDG ELECT PLUMB MECH
0 � 0
q p p LICENSED CONTRACTOR'S DECLARATION Job Description
V p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z 8 with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'oy intuutoreean fI Lich I/ USE EXISTING FURNACE INSTALL COIL & CONDENSER 10
j ^ License Class
y Date___46r2L& S Contractor X
ARCHITECPS DEC LA AT] N
1 < I understand my plans shall be used as public records 6 SUPPLY DUCTS UPSTAIRS 220, 110 HOOKUP 3 AMP
'dam DISCONN QCT BOX
4 G Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
y p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K,0, m
which requires a permit to construct alter,improve,deolish,or repair any structure
y H prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
2>< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 )q.Ft.Floor Area
Y.[— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $4850
f 5 9 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(M). 35624044 .0 0
❑I,as owner of the property,or my employers with wages as 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 does not apply m 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
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law 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 Contractors
License Law.
❑I am exempt under See. B tit P C for this reason
vner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,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
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wor �J_Co?�penspon Insurance carrier and Polity nu7 berate: r
Carrier�7�1 7� n at Polity No.:/ 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed 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,1 shall not
employ any person in any manner so as to become subject to the Workcrs'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 the Labor Code,you must
,J Z. forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[~e I hereby affirm that there is a construction lending agency for the performance of
a.7 the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
]z (.enders Address
U C) I certify that 1 have read dds application and state that the above information is
LL correct.I agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby authorim representatives of this city to enter upon the
U above-mentioned property fo ' pection purposes
(Wc)agree to ssve demnify and keep harmless the City of Cupertino against
rF.t liabilities,judgmc co an 'expenses which may in any cosy accrue against said City
U Z in
COMPLY WITH ALL NON-POINT Issued by:
Re-roofs
Sig pplicant/ContractorDale T Of Roof
MA ALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
,de,
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C3 Yes iso 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? 1
❑Yes Lge+o
1 have read ous materials requirements under Chapter 6.95 of Ore Califor-
ni Sof C ctions 25505,25533 and 25534.1 understand that if the building
a Certificate of Occupancy. Signature of Applicant Date
v
All roof coverings to be Class';.`'or better
Owncr utharizcd agent Date