B-2017-1284CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
21753 CASTLETON ST CUPERTINO, CA 95014-4704 (356 18 071)
OWNER'S NAME:
LICENSED CONTRACTOR'S DECLARATION
License Class S20 Lic. #445182
Contractor CONDITIONED AIR ASSOCIATES INC Date 08/31/2017
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
t. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 370Q of the Labor Code, for the
performance of the work for which this permit is issued.
0-A01
Ji z�, I have and will maintain Worker's Compensation Insurance, as provided for by
1 ri0/ Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that I have read this application and state that the above
information is correct. I, agree to comply with all city and county ordinances
and state laws relatingito building construction, and hereby authorize
representatives of this,bity to enter upon the above mentioned property for
inspection purposes. ; (We) agree to save indemnify and keep harmless the
City of Cupertino agairistliabilities, 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 Cyte o u is I Code, Section 9.18.
Signature Date 08103!2017
I hereby affirm that'I am exempt from the Contractor's License Law for one of the
following two reasons.,
t. 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)
i. I, as owner of the property, am exclusively contracting with licensed
contractors to rconstruct the project (Sec.7044, Business & Professions Code).
CONTRACTOR: PERMIT NO: B-2017-1284
CONDITIONED AIR
ASSOCIATES INC
SAN JOSE, CA 95125
DATE ISSUED: 08/03/2017
PHONE NO: (408) 291-2220
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
X MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
RELOCATE FURNACE; INSTALL (N) AC UNIT
Sq. Ft Floor Area: Valuation: $12000.00
APN Number: Occupancy Type:
356 18 071
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Kim Dunbar
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 08/03/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF
1. I 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.
z. 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.
3. 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
Worker's Compensation laws of California. If, after making this certificate of
exemption, 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.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agreeao 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 indemnify a4keep harmless the City of Cupertino against liabilities,
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.
Signature Date 08/03/2017
"A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 15532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Munici Chapter 9.12 and
the Health &Safety Code Sections 25505,
I hereby affirm that there is a construction lending for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional