02110162 CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT WCONTRACTOR INFO.RMATIQN°
Boll Pl5sANN ARBOR AV A PERFECT CLIMATE PERMrrNc02110162
DWBOONWIIE CHAO 10570 S DEANZA BLVD APPLWAT14Nls�/4y2002
DONE: 408 861-9545 SANITARY NO. CONTROL NO,
ARCIIFECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
µ0^t nO LICENSED CONTRACTOR'S DECLARATION
to FI MrcM1y affirm that 1 am licensed under provisions of Chapter Y(commencing J scription
awithScmiort70kdofIivismn 3nfmc Brorucs,and ProussioroCad,md my licensees NEW FURNACE & H�
in full tone and top.1 x31s
Z O'n4 License Class k•2O Lit.4
0'1, Date111 jContractor 1�
a�vi9 I understand my plans&hal M used as public mcochi
.0
w 3 a t; Licensed PmE.minnal
a0, OWNER-BUILDI:R DECLARATION DEC 1.1 2002
Y 1 hereby uftirm mat 1 nm exempt from the Cnnvannrs License Law for the $7193
m OO following mason.(.Section]1)31.5.Business and Professions GNc:Any city or county
X 2 which requires a Permit to construct.alter,improve,demolish.or repair any structure
w�'^ prior to its issuance.also rtyum.S the applicant for such Permit to lire asigncdstakmem
that he is licensed pursuanuo the Dnwimon&of the COnituners Licenc law(Chapmr 9 Valuation
AFD (commencing with Section]IkaB of Division 3 of the Business add Professions Code)or
y $ that he is exempt Wemfrom and the basis for the alleged excmpdon.Any violation of
Section]031.5 by any applicant for a permit subjects me apphcnl to a civil penally ofppl-N Occupancy
nut mom ran five hundred dollars(SWI Pane y Type
303 - ROUGH MECHANICAL
❑I.azowner .tBe pmpeny,m is emnainde with wagesu Weirsok soul.Buatioa
will do the wmh,and the stmcturt is not intended or mffcrt0 for salt(gee.]Ossa,Busitrss 3 04 — egDI MMjeAh
and Pmfmions Code:The Contractors License law does not apply m an Owner of 505 - F I NAL LL'1, grgtons
properly who builds or improves)hereon,and whodorsnch work himself or through his
own employees,provided Wal such improwments are not intended orolTened for sale.If. 507 — FINAL PLUMBING
howersr,em building or improvement is sold within one year of completion,the owrter-
wilder will haw the Damen of proving that he did not wild or improve for purpom of 508 - FINAL MECHANICAL
sal
❑ I.as owner or the properl,am exclusively com acting with licensed contraclon to
convect the project(Sec.7034,Business and Proomoom Code:)The Contractor's Li-
cense law docs not apply to an Owner of property who wilds or impross meson,and
who contracts for such projects with a comractorts)licensed pursuant o the Contractors
License Law.
D I r m caempt under Sec. B&P C for this rcazon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the fdlowing declaramons:
I haw and will maintain a Ceniftcate of Conttm to self lumre for Worker'sCnmpen-
w1inn,as provided for by Section 3700 of the laver Cade,for the rerformantt of the
for which this permit is issued.
w d hast nJ will maintain Wurkcrx Compensation In...az"aimed by Section
of the labor Code,for me performance of Bic work for which this Permit is issued.
My Wnrkcr's Drape un & n carrier and Policy number are: D
Can,
r. Policy NO.:
C IFICATEura EXEMPTION FROM ORKER
COMPENSATION INSURANCE
(This section need not Be completed if de permit is formic hundred dollars(SmIB
or kssJ
I¢nify that in the performance of the,work for which this Permit is issued,I Wall not
employ any pcmm in any manner m as tit Become subject o the Workers'Con,areation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
Becmme subject tu the Worker's Compensation previsions of the IaNu Code,you must
OO forthwith comply with such provisions or this permi l shall Be deemed mulled.
Z N CONSTRUCTION LENDING AGENCY
(-+ I heresy affirm that there is a construction lending agency for the Performance of
R 7 the work Por which this permit is issued(See.3097,Co,C.)
W� Q Lender's Name
z Lender's Address
V C) I certify that I have read this application add seem that me above information is
fL f' comma.I agree to comply with all city and county orroances and sere laws relating to
Q (..3 building conswaion,and hereby aulhonve mpmavmaJvcs of this city m enter upon the
D] aMve-memioned pmpeny for inspection purposes.
Hgy (Wq agree to save.indemnify and keep hmmless the City of Cupertino against
tjrry math.' ,judgmen¢,tt=1infld expenses which may in any way acerae against mid City
inemn. goose NDIRATANDStA ANDorm
Issued by. Date
APPL CANT UNDE TANDS AND WILL COMPLY WITII ALL NON-POINT
SOU I..RE ULAT S.
Signal if ter pp scan actor l Dalt Re-roofs
HAZARDOUS MATE SDISCLOSURE Type of Roof
ill the applicant Or future building sex t smo,nr handle himsdioe material
as defined by the Cupenim Munit Pal Crile,Chapter 9.12.and the health and Safety
code.secrn 25532(a)r All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will Be applicant m mor wddm ,ecu yu;pmn If a roof is installed without first obtaining an inspection, I agree to remove
Pn s t path use a t !dMana which b' P g
emit hvurJnus air contain in
is
1 defined try the Bay Arca Air Quality Management all new mate for inspection.
Dinricl'/
Q Yes
I have,k Sam,the uJv,, dmusmekr)5,255ak 3and25VD.1undcru Charm,fi95ofmc Caldron /
dellnoc Safely Gak.Saad,that iI is in 33no1%3a.l understand Occupant
tot the
ors end a tenant,that it is m rc&Paroihil;lY to notily the rw:euPnt nl the
reymirt'c oven:na tie emelpm,rmis non certirnam ser Icy. Signat
ure ofvpplicant Date
cr it authorwel agent "�DallelI/�^ All roof co rings to be Class "B"or better