02120102 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR4INFORMATI.ON:
BUILDING ADDRESS: CONDITIONED AIR PERMITNO.
861 BETTE AV 02120102
OWNER'S NAME: 1701 LITTLE ORCHARD ST APPLICATION SUB DATE.
SHELLY WESSELS 12/30/2002
41 HONE: LIOB 291-2220 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEHR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PDO LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affon 11m 1 am licensed under provixions of Chapter 9(commencing p
with Section TIIXF,of Division 3 ofthe Business and Professions Code.and my license is
in fullforee LI( 3 i[X ,SI b�—_ REPLACE FURNACE
oi44 Li[ense Cl
OZ C m
ARCHITECT CLAR TION
1 understand my plans shall M used as public records
O U
W Q
Licensed Pmfcssinnal
OWNER-BUILDER DECLARATION
ser<f 1 hcrchy.snoihet 1 am exempt from the Cnsions Code:
:License Law for the
p O following reason.(SeNnn 7831.5,Business and Professions Code:Any city or county
�$6� which requires a permit to construct,alter,improve,demolish,or repair any structure
prior m its issuance,also requires the applicant for such permit to file a signed statement
FsZ?< 'hat M is beamed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area $2Y46tion
FO (commencing with Section 7000)of Division 3 ofshe Business and Professions Code)or
$ Na'he is exempt therefrom and the basis for the alleged exemption.Any violationof
Section 7031.5 by any applicant for a permit subjects applicant to a civil Penalty of Occupancy Type
not more than five hundred dollars(1508).
❑ L,as owner ofthe property,or my employees with wage m their sole compensation, 301: — ROUGH
will do the work and he structure is not intended oroffered fmm1e(Sec.7000,Business
and Profession Code:The Contractor's License law does not apply he an owner of 303 - ROUGH fail Ons
pe
pmny who bullets or improves thereon,and who does such work himself or through his
Own employees,pmvided that such improvements are not intended oroRered formle.if, 304 - ROUGH ELECTRICAL
however,the building or improvement is sold within one year ofermpinion,the owner- SOS — FINAL ELECTRICAL
builder will have the burden of proving that he did not build or improve for purpose of
sale) 507 - FINAL PLUMBING
❑1,as owner of the property,em exclusively convening with licensed contractors it 508 - FINAL MECHANICAL
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of property who builds or improves themon,and
who contracts for such penjecu,with a contractor(s)licensed pursuant to the Connector's
License Law.
❑l am exempt mum,Sm. ,B&P C for this reason
Owner Data ".71
WORKER'S COMPENSATION DECLARATION —'\
I hereby affirm under penalty of perjury one of the following declarations:
I hove end will maintain a Certificate of Consent it)self-insure for Worker's Compo ' r �-
.he..m provided far by Section 3700 of the Labor Code,for the performance of t a
work for which this permit is issued. 11 , XPIr
❑1 have and will maintain Workers Compensation Insurance m required by Section j
37110 of the"Indicode,for the performance of the work for which this permit is issued.
y Workefs Compensmion Insurance canner Po' number are:
wrier: Y�kfAf/1� kMPlDff J I�1�431lld1
CERTIFICATE OF EXE MM FROMWORKERS'
COMPENSATION INSURANCE
(This union need not becompleted if the permit Is for one hundred dollars III out
or less.)
I certify that in the performance of the work for which this permit is issued.I shell not
employ any person in any manner so in in become subject o the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject m the Worker's Compensation provisions of the Labor Code,you mus'
OO forthwith comply with such provisions or this Form it shall be deemed revoked.
V) CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that them is a convection lending agency for the performance of
pa, > the work for which this permit is amed(Sm.3W7,Civ.C.)
10 UnitName
z Lenders Addmm
U Q I certify Na'1 have rad this application and mate that the all information is
D. is correct,l agree to comply with all city and county ordinances and stale laws relating to
O Vbuilding construction.and hereby authonee mprasentativas or this city to enter upon the
ehon,mmilioded property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against 1
V) liabilities,judgments,costs and expenses which may i n any way accrue against said City _
U in consequence of lM gmming of this Permit. IJT✓/
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by:3 Date
OURCE REGULATIONS.
A�/ �fNt�l� 17x3 Re-roofs
Signature o(Applican(Commcmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building cecupan'store or handle he ardous material
in defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532a)7All roofs shall be inspected prior to any roofing material being installed.
Will due applicamerfuture building Occupant use equipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
Ihue mail thodezardnusm 5.505,25533 and 25534.
rderamr695 of the Culding V ^— r r I I3-I3 h�
niullonith&Safety hehamnlinns25erials 5533 andnts under hapten Nat if the building t/t/IM'I ' O/
does not currently hove a tenant,that it is my responsibility m artily tM ¢uFant of the
requirement which most On pdos dssuncc ofa Ccn'¢a o c anc7. Signature ofplicant Date
nermauthomcd em a� DareI All roof coverings to be Class "B"or better