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CITY OFCUPERTINO
BUILDING DIVISION PERMIT��`T'�RZNXa~nI23�TA'TIdN
BURRING ADDRESS: .
CONDITIONED AIR
PERMITNO.
OWNER'S NAME :
1701 LITTLE ORCHARD S .T
PLR7nn�s
NE:
(408)291 -2220
O. CONT
SANITARYNROLNO.
ARCHrfBCrtENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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I hereby affirm That I am licensed under provisions of Chapter 9 (commencing
with Section 700D) of Division 3 o the Business and Formation, Code. and my It.. is
in full to= License Classntl e0ed. LloAs
REPLACE FURNACE FINALE®
Dam Conlrcmr
ARCHITF.CI -S DECLARATION
I uMCrwnd my plant shall be need as public rerorde
MAR 19 2003
Liccncd Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor', License Law for the
BUILDING
following mason. (Section 703 1.5. Business and Profession Code: Any city or county
which requircs a permit to construct. elms, Improve, demolish, or repair any structure
prior to its issuance, alto rey doom the applicant for such Permit to 01e asigned etsmmenl
that he 1, licensed pursuant in the previsions of the Contractor's LlcenO Law (Chapter 9
Sq. Ft. Floor Area $r)��tion
(commencing with Section 700D) of Division 3 of the Business and Profeclo ut Cede) or
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that W la exempt therefrom and vie bash for Be alleged ewnption. Any violation of
3 A`V"l2A?gr0 0 Occupancy Type
SMlon 7031.5 by cry applicant for a permit subjects the appllcam In a civil Penalty of
not mom than Dve hundred dolnm (MI
D 1, ss owner of the property, m my employees with wages As then Ole compeasstiw.
301 - ROUGH ctians
will do the work, and the muclure is not intended or offered forsen(S". 7044, Business
and Prafwlom Code: The Cono times Licente taw data Act apply be an owner of
property who Wildaodmprom, thereon. andwho d=asuchwarkhimselforthrough hit
'
303 - ROUGH M CHANT AL
own employees, provided that such Improvements Am not intended ara0ered formic. If,
304 — ROUGH ELECTRICAL
however, the building or Improvement Is sold within one year of completion, the wear.
builder will hew the burden of proving that be did not build = Improve for purpose of
505 - FINAL ELECTRICAL
.1. .
507 - FINAL PLUMBING
D 1, as weer of the property, am excludvely contracting with Immed commons m
consumer the pmjm (See. 7044, Business and Pmfemnce cede:) The Consents, U•
508 — FINAL MECHANICAL
am law doe, Out apply O an atom of properly who builds or improves Benno. and .
who contracts for such projects with a convenor(s) licensed pora am to the CAntrsemr,
License law.
D i am exempt under Sec. . B & P C for this mason
"
Owner Dam
WORKER'S COMPENSATION DECLARATION
III lemby dEnn under penalty of perjury arc of the following deelssadona:
I Mveand will melnWn a CeNBesm or Camem to sett -imam for Worker's Carman-
Asian, allrovided fee by Section 3700 of the labor Cadft, for the performance of the
'
wink f which this permit Is issued.
ve anl will maintain Worker', Compensation Intense=, At required by Section
3700 of the labor Code. for the perforreacc of me work for which this permit Is issued.
My War Pana�mminJPanamint Innssu,ran =c cr and Policy numMr g�mc
,/¢'q9m
Cesder.� Policy No.:
CERTIFICATE OF EXEMPTION FROM WOR E
COMPENSATION INSURANCE
Obn =mire nerd not W eomplced If de permit is fm Ace h.ndredd.l W a (11100)
or less.)
I =rdfy that in the performance of me weak for which this parent, la Issued, l shell n=
-
employ any person in any manner O U in becom , subject o the Woeken'Compentation
Laws of California, Dam
Applicant w
NOTICE TO APPLICANT. If. After loakfing this Certificate of Exemption, you should
become subject to the Worker', CamPenssmion pmvlelone of me Labor Code, you mud
' forthwith comply with such pmvtsions or this permilshell be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
1 hereby alarm that dmrc Is a coastnetiw lending agency for the Performance of
the work for which this permit Is issued (See. 3097. Civ. C.)
1 fender', Name
Lender's Addma
i I certify that 1 hew read this application And some that the above information h
correct. 1 agree to comply with all city and county ordinances and slam taw, relating to
building construction. and hereby sutho me mPresent 1LIM of sun city to enter upon me
t shove- mendoned property for Impaction pugmee
(We) agree m ass. Indemnify and Imep ham iea the City of Cupertino against
j IIebI11Be;JudgmenU. mass and expenses which may In my my amve against said City
APPLICANT UNDERSTANDS AND WILL WILL COMPLY WITH ALL NON -POINT
Issued by: - Date
SOURCE REGULATIONS.
Re -roofs
Type Of ROOF
Signature of AppliuHAZARDO Data
HAZARDOUS MATERIALS
ccupant Tore car handle materiel
WIII the applicant building Occupant two
mforum
Health
ss dcOmd by the Cupenlno Municipal CoM. Chapter 9.13, and the Halm end Safety
Co
ode. Seerion 15533(,)? &I _
❑Yta
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Wills sppinant err future building a=upam me equipment or devices which
It heardous air conWnlnants As, d by the Bay Area Air Quality Management
all new materials for inspection.
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I have mad the haardtma mamrienmquimmenu underChaPmr6.95 of me Celifor.
nia Halm &Safety Cade,Secdane 25505.25533 and25334. 1 understood! lhatiftho Wilding
S/' 3 /O2 i
does co, currently new a mount, that it Is my fespondbility m rwdiy the =cupp r the
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requtmmena ,u which must be me or to in afi CcruR =m orccupm 5{`/��
Signature of Ap cant Date
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All roof coverings to be Class "B" or better
Owoersorr alomorizWd gd Dam