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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