05050038 CITY OF CUPERTINO rh`i' ta> ' �` t •4 .
BUILDING DIVISION PERMIT CON'TRACTORINF' RMATION
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BUILDING ADDRESS: FOOTHILL A/C & HEATING ""n"'O 5050038
OWNER'S NAME: PERMIT ISSUE DATE
PC)WP.P TNT PA-RIZ34 RD- y106/2q9l
NE: SANITARY dAOL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
o O O O O
L10o LICENSED CONTRACTOR'S DECLARATION JbDescription
0 1 thereby affirm N
at 1 am licensed under provisionso
of Cimino,9(commencing -
with Section 7000)of Division 3 of the Businesssed ProfcuNm Code.and my liceam is
N in mB fora and WL ! ADD 1 AC UNIT
t,9Z ;M..Cis Lk.g
Z Date Canlracbr �� v �ry� 7.1 '
3 ARCH17EcrSDECUlfAT1DN S CONTRACTOR: FOOTHI g■j®, ��%!aG
1 ummeamd my plan"I be used u public n comas
b
Licensed Professional [
OWNER-SUILDER DECLARATION
2� ZOOJ E 1 hereby o111rm Na I am eumpt Truth Na Contractor's License Law for to
i Oo fallowing Mason.(Section 7(DI.S,Baiutss and Profession Cook:My city or county
112 which requires a permit M construct,after.improve•demolish,or repair any structure
k- S^ prior to its issuance.also requires the applicant for such permit M rile signed stsrem.nl
that W 1.licensed pursuant to the provisions of Ne C.m.tori Umae l.Sw(Chapter 9 Sq.Ft. Floor Areaaluation
(commencing wide Section 7")of Division 3 of ftBusixu and Professions Crum)Or
.. Nat W Ins exempt therefrom and the basis for the alleged eumpdon.My violation of
Section 7031.5 by any appllcut for a permit subjects She applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred d.IW.(5500).
❑I,uowrwof Nepropwy,wmymaploymwiNvnguuthehmleca melon,
will do the wouL.nd Ne structure is rat intended Muttered fonam(Sm.7061,Busircu014 . (](]
and Professions Code:The Contractors License Law dm col apply to an owner of Required Inspections
prapeny who Wilds or improves thereon,and who dm such work Mmulfor through his
Am employee,provided that Such improvements see not intended!Or offered for nit 11.
however,the Wilding or improvement is Salo within one year of completion,the owner.
builder will haw the Wooden of proving that a did not build M Improve for purpose of
SAM.).
❑1.a owner of to propenY,am exclusively conuuning with liamed m nnumm,M
coawcl dee project(Sec.70x,Business and Professions Code:)The Canuacars U.
cense Law don not apply to an owner of propeny who Wait"or improves theman.And
who comneu for such projects with a contractor(s)Ilaaed pursuant to dee Comruara
License Law.
Q 1 am exempt antler Sec. .B&P C for deft reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc Of the following declarations:
I haw and will malnuin•cerdrnatc orcomnt a ul6iaum fee Wob.rsCommn-
sauan•as provided for by Section 3700 of the Labor Cade,for Ne pcaorm nine of the -- -
work for which Nis Pamir is issued.
❑I haw and will maintain Workers Campeesation Insurance,As required by Section
3700 of the LeWar Code.far the performuce of the work for which this permit is crowd.
My Worker=Cm wsonlaurarwamer and policy number are:
Grier. Poliry ISS,7.9�-04
CERTIFICATE OF 'XFM Pf70N FROM WORKERS'
COMPENSATION INSURANCE
(This smim need Wren compiered time permit is for onchundnd dollaa($100)
Or ler.)
I artily that in the performance of the work fee which this permit is issued.I shell net
employ any penon in soy manner m As in bacome subject lathe Workers'Compensation
Laws of Califoreia.Dae
Applicant
NOTICE TO APPLICANT:If.after making this Campeau,of Exemption.you Should
become Subjm a the workers Co e,cwatian provisions of the LAW Code,you mus -
,JO forthwith comply with Such provisions M this permit shall x revolted.deemedrevolted.z` CONSTRUCTION LENDING AGENCY
[r I hereby Opme that them is a construction lending agency for the performance of
lYi the work fee which Nu pCnuit is issued(Sec.3097•Civ.C.)
Q Landoe.Nun.
O z Lender's Addreu
U O 1 cenlfY that i have read this application and SUM that the Show info .Om is
Iy cont.I agree to Comply With SII City and County ordinances and sum lawn retailing In
O LrJ' building convection,and hereby authorize nprasemadvea of this city in enter upon the
4 mom-mensomtd property for WpcLdW NoTs sea
(We)agree M aw,indemnify and keep humler the City of Cupertino against
wFw rrAA liabilities judgments.ens sed expenses which may in my my acme agelnt aid City
in
of the
U�'••� APPLICANTeUNDERSTANDSof this AND WILL COMPLY WITH ALL NON-POINT Issued by: DaleS'-
SOURC CU TION�.--�
S sf� Re-roofs S ,
signature of cmuco or 'Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will da applicant or future building accupsntaome or handle hauNaa material
AS defined by Ne Cupertino Municipal Code.Chap cr 9.12,and dee Health and Safety
cod,Section 2553:(a)7
❑Yes CN. All roofs shall be inspected prior to any roofing material being installed.
Will de applicant sir future building Occupant use equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
.It heardnus air contaminants an defined by the Bay Area Air Quality Management all new materials for inspection.
Diaria7
❑Yes &No
I haw mad the hauamnusnawrialsrequiremens under Chapar6.95 of dee Glifar- -
nia Health&Safety Caoc,Sections;25505.25533 md25534.I undersand thsifthc building
dm not currently haw a tcoane Nam It u my responsibility a notify dee occupant of the
nquireme wlliC Mine aumaar,ceuinatcorampawy. Signature of Applicant Date
Owner w.ulh foda cot D te
All roof coverings to be Class "B"or better