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12080119CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10614 JOIIN WAY OWNER'SNAMI:: LL'EYAOPANDJEANC OWNER'S PRONE: 4084464651 rpicLICENSED COM*RAC`fOR'S DECLARATION License Class C-20 Lie. N 2 5:g' _& Contractory 11CS' ry�`�/''[Date 7//ei� 1 hereby affirm that 1 am licensed under the provisions of Chaptcr 9 (conunenchn, with Section 7000) of Division 3 of the Business S Professions Code and that lib' license is in full force and effect. 1 hereby affirm under penally of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided l'or 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 provided for by Section 3700 of the Labor Code, for the performance of Ore work for which this permit is issued. APPLICAM' CERTI FIC TION I cenify that I have read this application and state that the above infomhation is correct. I agree to comply with all city and county ordinances and state Imes 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 indemnify and keep harmless the City of Cupertino against l iabilides, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signaturezitz w ❑ OWNIiR-BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the stmcture is not intended or offered for sale (Sec.7044, Business S Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sce.7044, Business & Professions Code). I hereby affirm under penalty of perjury line of the following three declarations: I have and will maintain a Certificate of Conserv to self -insure for Worker's Compensation• as provided for by Section 3700 of the Labor Code, for the perl'onnance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certit)'that in the performance of due 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, alter making this certificate ofesemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. \I'I'I -IC.\\ I'CF:IYI'IPIC\"PION I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances mid state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned propertyfor inspection purposes. (We.) agree to save indemnify and keep Immhless the City of Cupertino against liabilities, judgments, costs, and expenses which may aceto against said City. in consequence of the granting of [his permit. Additional]y; the applicant understands and will comply with till non -point source regulations per the Cupertino Municipal Code, Sectio 9.18. Date CONT'RACI'OR: VALLEY IIEATING R COOLING PEIRMITNO: 12080119 1171 N 4'1'11 Sr DA'Z'E ISSUED: 08/102012 SAN .IOSIi, CA 95112 I'IIONF NO: (4118)294-6290 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r AIECli r RESIDENTIAL r COMMERCIAL r .JOB DESCRIPTION: ADD A/C R17PLACE 10 SUPPLY DUCTS, RELOCATE NEW FURNACE TO ATTIC Sq. Ft Fluor Area: I Vulualion: $14000 APN Number: 35918003.00 1 Ocemp:ngy'I'ype: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: [J —, — 11�1/7k/1-'� S . Date: RF: ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVEIRINGS T'O BE. CLASS "A" OR BF'17FR IIA%AltDOUS MATERIALS DISCLOSURE have read the hazardous materials requirements under Chaptcr 6.95 of the California Health S Safety Code. Sections 25505. 25533, and 25534. I will maintain compliance with the Cupertino \I unicipal Coda Can pier 9.12 and the Ileallh S Safety Code.Section 25.532(a) should 1 store or handle hazardous material. Additionally. should I use equipment or devices which emit hazardous air contaminants as defined I)v the Bac Arca Air Quality Management District I ,ill maintain compliance with the Cuperlino Municipal Code, Chapter 9.12 and the Ileallh S Safety Code. Sections 25505, 25533, and 25534. O m int ter rtr nuthrr�rizeLdagen t%� �Jia✓i?.c-�F�=4.4/iT_.i'�tlDalc' 0�2 CONSTRUCHON LENDING AGENCY I hereby affirm that there is a construction leading agency Ibr the performance o' work's for which this permit is issued (Sec. 3097. Civ C.) Lender's Nanne Lender's ARCIIITEICI"S DISCLARAT'ION understand my plans shall be used as public records. GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTI 10 I (408) 777-32288 --/FAX (408) 777-3333 • buildingecuoertino.oro ❑I?LUh1GING l/_I �YiKIIANICAL ❑F:LEiCTRIGV. ❑MISCELLANFOUS MEP MISC PROIECT ADDRESS NPH#' 166-10 :T4J LJ.. ✓ OWNERNANIEPHONE I e� L P.. &IbVL STRWFADDRESS CITY, STATE,LIP FAX .� /'G/4scrY raw .� bf CONTAQ NAME PHONe E-NIAII. STREFr ADDRESS CITYS TATE, LIP FAX ElOwNER CI OWNER -BUILDER ❑ OWNER AGENT' ❑ CONTRAC.S rOR 21OM1TRACFOR AGFNr ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONrRACFORNANIEvi �CC•b�r.l LICENSE NU}iBERLICENSETI BUS. LICti NeR lid L COMPANYNAME % E-%IA1L FAX STREET ADDRESSJ'r N. 1114 `/ J CITY. STATE. LIP`` S /95/,n 9 / PHONE 7� A RCI HTE CUENGINEER NAME LICENSE NUMBER BUS. LIC9 COMPANY NAME F. -.MAIL FAX STREET ADDRESS CHT, STATE, LIP PHONE USE OF 'FDar DUPLE\ ❑MULTI-F\MBA PROJECTINWILOIAND C1 YES PROJECT IN ❑VES IS THE BLDG AN ❑YES BUILDING, []COMMERCIAL URBANOTERFACE AREA ❑ NO FLOODZONE ❑ NO EICHLER HOME! ❑ NO DFSCRIP-HONOF WORK 'J r ^ A % Oa r. A ( A/C . cr r.N • Cs r'4 e �e %Os � e d;Ic•�S/l12elr �.r c�uc s F r: o t o old i e n e r TOTAL VALUATION: /(-/ COC — RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authari' representatives ofCupenino to enter the above -Id miffed pfapeBy for inspection purposes. r G� Date: Signature of ApplicanUAgenC ^ / SUITI_FNIENTAL INFORMATION REQUIRED OFFICE USE ONLY OYER-niE-COUNTER - 1 ❑ EXPRESS ❑ STANDARD Z ❑ Id REF. ❑ MAJOR d16P,Wsc1Ipp_2011.da revised 06121/11