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CITY OF CUPERTINO
DIVISION PERMIT
- - - -
BUILDING
fiCONTRACTOR,INFORMATION
BUILDINCADDREss:WEIGEL
MECHANICAL & REFRIG
PERMIT No 04100174
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY - - C N OL NO. -
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
- Job Descrl P" p
1 or, T affirm Net 1 am IiauW under provisions of Chapter 9 (Commencing
with on TOfNB pl Division Sof the BuArlwk�d Fofcsdnu Codc.e myliccnse is
..
-
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®
full to
inmumroean 7 0 � y0��
®r VO UNLS
HEATER REPLACEMENT
CI � g
Dam
Date ContractorARCH
ECI'SD 2TION
t
NOV_,17- 2004_.- -:
2004-
I plans
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��1 ud7d}f�rs�und my plans snail 11c uxd as t.Wli
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OWNER -BUILDER DE CLARATION
R-emmpt
_. ��/,%�
I Wmby effinn Nn I from tW COmaaeter's License Law for tW
lal `(\sYYnll fpt�ffi�_77
UI"L D'(PUNG
following moan. (Secuun 703 1.5. Business and Professions Calc: Any city car county
which oCtim. a permit to ennarect, mcr, improve, demulsh. m repair any auuctme
! prior to its issuance.also requires de applicant formeh permit In rile a signed statement
that M is liccnscd pursuant to tM provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valua Ion
(commemmg with Section 7") or Division 3 Mthe Business and Prorassiou Code) or
that W is emmpt therefrom and the bus for she Alleged exemption. Any violation of
Section 7031.5 by airy applicant fora permit subjects the applicant to A CMI penalty of
.,,.a,
3 %��Yr�g� O
Occupancy Type
P y'
not more than five hundred dollars (Mr.
L owner of propury, re omploym wrtb wagea dcanpBwness
(role
andBusiness
will dothcuumse, wok endo: structure a
o is
edousred FormicApply
Required Inspections -
tori Limuce,tended
and Prtywh obu Code: The La to An
Ldwho law deo ret apply lf an osvar car
-
mttruart
worki his-
suthimpro manta Aoesauchoulodmattered
ownenywyees, provided thatsuchroe sale.,-
es,
ofeemortaed
saidwdammot
lown..loyers,Provided
Ne owner-
bowew. the Wilding or improvements said within one yea ofunprom
will have Ne burden of proving that W did wi Wild or improve for puryase of
for
bale.).r
sale.).
❑ I, as owner or ate propen,,, am exclusively Contracting with licensed contractors to
conaruct the project (Sec, 70,14, Business and Profusion Code:) The Contractor's Li -
cause law docs not apply to an owner of property who Wilds or improvea thereon, and
who Contracts for such projeeta with a conaanm(s) licensed pursuant to the Contractors
License law.
0 I Am escmpt under Sea ,B&PC for Nis reason
Owner Date
WORKER'S CDMPENEATION DECLARATION
I hereby farm under penalty or perjury aro of Ne following declareuom:
I haw and will maintain a Certificate ofConunuo self -insure for Workers Compcn-
.. .._..._. ,
titian, u prmidW for by Section JTgO of Ne IaWr Code. Iso the Performance of de
work for which this permit is issued.
❑ 1 ban and will maintain Worker's Compensation Inmrunce, as "Cited by Section
37M of Ne labor Code, for Ne performance of the work far which this pe.I, s issued.
My Workc Co p Insuran rri and Per,
]nu�mbe�r�art:
'ter. r cY
Ca a.:1..LL_L.IJ
CE IFIGTE OF %EMPf1�OM WORKERS'
- -
COMPENSATIO SO,
--
(This sectim need not W eomplead ifft permit is fa one hundred dollars (SIM)
or It..)
I cantly Net in the performance of the work for which Nis permit is issued, 1 shall not
employ any person in my mmncrso As to Weome subject to she Workers' Cempeamuon
Laws of California. Dae
Applicant
- - - — - - - - _-
NOTICE TO APPLICANT: IL after making this Comficate of Exemption, you should
become subject to the Worker3 Compc art on previsions of one, Labor Code, you must
forthwith comply with such previsions car this permit shall W deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirm than inert is A eotuuucumt imiling agency for the perfurmance of
/
the work fur which this permit is Issued (Sec. 3W7. Civ. C.)
Lender's Name
Jam/
'
Lender's Address
I canify that I have read this application and sae Na the above informed.. is
correct. l agree 19 comply with all city and county ordinsams and sae laws relating to
building construction. and hereby minnow repremmativu of this city to color upon the
abovemenuonad property for iupceuoo
(We) agree to ave, indemnify and keep harmless the City of Cupenino against
Iiaconsc,umcc a the an and expeuca which may in my way aamie apiut acid City
which may
m PLICAN tee of the or this permit.
{�
RTAgranting
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -P01
Is$Ued by: Dale
SOURCE REGULATIONS.
�� G
Re -roofs /
Sin ofApphe"O'Ca onseno Da
HAZARDOUS MATERIALS DISCLOSU
Type Of ROOF
Will tWapplicmr or forum building.ccupmtstore orb,n vallous maesal
As defined by the Corcoran Municipal Code, Chapter 9.13, and the Health and Safety
code. sttue. zs5320)+
❑ Ya N.
All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or mare building «a equipment
Pp C pant tau c i t or devices which
If a roof is installed without first obtainingan inspection, I agree to remove
P
emit harzrdous air communan u defined by do, Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
I haw mad the havaNnus alcrialsmquimmcnuunl rChaper6.95ofNcCalimr-
nsHcalN&SofctyCa ,Sa60u25%5.25533md255M.lun&c LhatifNc Wilding
does not com mily hats: agemans, that it s my respouibility m until, do amupmt Of the
rcgvimmenu wmmh and; nor wtwo= riwcer«a ry.
Signature of Applicant Date
All roof coverings to be Class 'B" or better
ow r ter auNori'rcd agcm Dae