04120026CITY OF CUPERTINO
q
CONTRACT,y INFORMATION
- - ------ -- --
BUILDING DIVISION PERIVIIT
Y:� .P [%✓moi.'.-F,`aiY..$tlxwA�Flr 1X .fieri'
BUIL DING ADDRESS:
SAN JOSE AIR CONDITIONING
Pa" "'10412OO26
15717 AMHERST DR
OWNER'S NAME:
PERMIT ISSUE DATE
JAMES KEATING
880 N T
NE:
SANITARY NO. CONTROL NO. -
(408)286-2047
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTR S DECLARATION
Job De i
1 M. i u;dcr
IMI 1 am Itcenscd under provisoes 0r Chapter 9 (commencingI,
wills Section 7 ) of Divi¢ion lof the Business atb Profusions Code. end my license is
and
in rase fame Ones erfrc �[Lim.{'
REPLACE FURNACE
Dames des Conlnctar_,SQ O
ARCHITECTS DECLARATION
- DEC'} tt'1
C 2004
I understand my plans shall be used as public records
BBpBl��� p n
Ig H II
Licensed tonal
OWNER-BUILDER DECLARATION
-
B I
1 hereby exempt from Ilse Conunnoos License law for the
encs Nat 1
IIIItlfN'I pry!!
followingmemon. . sac 1. Profasons Code: Any city orcounty
](131.5,
t. aitasand
t0 construct. alter. Improve, demolish
which mqus a (anion or repair any surinatmstatement
e. also Permit t
u
priorwits issuance,alsorequitra po applicantthe Cohpermin0t Ieasigned eummcnl
those
Sq. F[. Floor Area
Valuation
(comma cccnsedpursuan 7fNepmvisiovofof cBummriLi¢nselaw(CMpmr9
(commencing of the
vi Code)
of
Business and Profeson.
]0o0)the Deal(
.
pt thomeon
Nat Meu tempt Oemfmm ale IK Ease for Ih slcgcd exrsnpuan. My violation of
r alleged M on
Semmi 7031.5 by my applicant for a permit subjects the applicant to s civil penally of
3 3P&X$Qffi*cr0 0
Occupancy e
P
not mole Nan 0n hundred dollars (1500).
y •J P
❑ 1. as owner of the property, or my employees with wages m their sole compensation,
will do the work end Ne trema is not intended or offered for side (Sec. 4041. Rumbas
and Pmreadoes Code: The Commcors License Law does not apply in an Owner Of
Required Inspections
proper he Wilds Ortmprovesthermn,end whadociauchw«khimseuor Nsough his
'
own employes, provided Jwsuch improvements art not intended oroffered for sale If.
however. Ne Wilding or improvement iamld within one year ofemopletion. one
builder will have she bunden of Proving IMI M did not Wild or improve for purpose of
- " -
.It.).
Q 1, as owner of IM pmpcnY, am exclusively convening with licensed mnumlors or
construct the project (Sec 70a 1, Business and Professions Code:) The Contractor's U.
"
cards law dura not apply to an owner of pwpeny who builds or uniform thereon, and
-
who concocts for such projects with a cantsacmor(s) licensed Pursues w tM Contractors
License Law.
❑ I am esempt under Sec. . B & P C for thea reason
'
Owner Date
WORKER'S COMPENSATION DECLARATION
1 Mreby &Man under penslly of perjury one of the following declarations:
I ham and will mutual a Cenoam of Conscnl w self-insure for Wmkei sCompen-
satton, as provided for by Section 3700 of this labor Code, for Ne pesfmcconce of in,
work for which this permit is issued.
❑ 1 M and will maintain Workers Compensation Insurance, as me uhad by Second
37000 Ne labor Cmarortheperfarm aflo, rk for which this permit is issued.
W rmes mPensalion Insurenm mrin miryroma ran:
Ca Ncy No.:
CERTIFICATE OFEXEMPTION FROMWO KERS'
COMPENSATION INSURANCE
Mi¢ section need not he completed time permit Is foronc hundred dollars (SIM)
or tess.)
I certify that in the Performance of the work for which this permit I$ issued. I mall not
employ any parson in any manmrm u or become subject to the Workeri Compensiden
Laws of California. Data
Applicant
,
NOTICE TO APPLICANT: It. after making this Cmi0cae of E¢mption, you soul
amino subject to the WOr bcri Compensation previsions of IM labor Code. you must
moh-ith comply with such proem s On hid Permit shall W ducmcd revoked.
CONSTRUCTION LENDING AGENCY
1 hereby of ina that them is a conswciinn lending agency for the perfmmance, or
tho fur which Nu perrnil is issued (Sea 309]. Civ. C.)
Lenders Namez
Lwork
(.enders Address
1 certify that 1 have std this application and slam that the above infommiun is
correct I agree to comply wish all city and county unbalances and mute laws testing to
Wilding cansuuction, and hereby authorize repraaentaovra of this city 10 enter upon the
above-mentioned properly for imKcuonpurlwsec
(We) acts to save, indemnify and keep harmless the City of Cupertino against
0abilidu,judgmcn6, costa and cxmnses which may in any way Ocean agatnstsaid City
in this Permit.
CANieU
APPL NDE STANDSWILL COMPLY WITH ALL NON-POINTIssued
by: Dale
SOURCE REG A N .
Re-roofs
'
Sig ApplicanUCanRDO Date
HAZARDOUS MATERIALS DISCLOS
Type of Roof
II applicator (mune or handle material
Ca
c, Chanumrc
y t Heanaw
as defined by the Cupertino Munitlryl COM, Chapter 9.12. and the Health and Safety
Municipal
ode, Section 25532(a)?
[_]Y. o
All roofs shall be inspected prior to any roofing material being installed. ....
Will the applicant or future building Occupant rte equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
mil hazannus air contaminants in de0ned by the Bay Area Air Quality Management
all new materials for inspection.
DislriaP
[D Y., N"teESU
I have rent the hxzannas materialsrc,tudements under Chapter 6.95 ofthe Califoo
niaHca10&SafctyCode,Sed.25505,25533and25534.1undcrsmndthuifde Wilding
leas not currently ha qle i, Nal it s mmaponsiM1ility m rodly Its occupant of Ne
m immen which a b p 0 1 eofaCemrc��upaney„-' /
i
Signature of Applicant Date
All roof coverings to be Class "B" or better /
owner or authmiced agent Date T
CITY OF
�UPEI�TINO
M.
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
PERMIT #
I am not using any subcontrac • �—
L� Signature Date
Please check applicable subcontractors and complete the following information
-- -v
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
-- -v
Date