03020052 CITY OF CUPERTINO �`
BUILDING DIVISION PERMIT �CONTRACTOR INFORMATION•°"�
BUILDING ADDRESS: PERMIT N0.
OWNER'S NAME: APPLICATIO
TjArC4ARn qARTMA RT AT
NE: - SANITARY NO. CONTROL NO,
ARCHIECT/ENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'Bpo LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provision of Chapin 9(commencing Job Description
with Sado"? )of Dividan3of Bre Busnexa an rofeuionx o c,and liccnseia
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$p_b u�r��:crf = D ua.a REPLACE FURNACE
" A�crs�a` AIG CONTRACTOR: COMFORT HEATING & AIR
I undcruand my plan shall he used lic recoNs
6G
c�n Licensed Professional
<3 OWNER-exempt frDECLARATION
f I hereby.(bore than 11. exempt from the Gonion Cot License Law for the
i O O following mason,(Section]PHLS,Business and Prolusion Code:Any city or
stcovey
+,$r which nquircsa Pmmit toconstruct,ealterimprnw,h permits rirepairany airuciure
FZ1,° Mat heor A,t fienow pursuante,also toMsiWvisiapponsof the such permit Bcomle ab Loedshapter l
< NeiheullansedPuntion70NeofDiviont,3of ft usbusssLiccnaaxlsw(Cheper9 Sq.F[. Floor Area Valuation
^� (comm is exempt
with Secudefro and0fid t f Diu r Me al B ed exemption.
on.Any
Cede)or
Nal he la exempt Nenfrom and the bssu for tlb alleged exemption.Any violation of
not
Section 7031.5
m 1.5 by nmaRa lent ftoifsrormu tubkcu Ne applicant m a civil penalty of APN Number Occupancy Type
❑I.ssownrofBx property,or my employe with wgu as Ne"vtole campewtion, 36932014 . 00
will do Ne work,and ditti ucture is not intended o affexd for mak(Sec.]014,Basinut
and Profusion Code:The Contractors License cow den an,apply to an owner of Required Inspections
property who builds or improvesdamon,andwho doetauch work himxlfor through his 301 - ROUGH PLUMBING
own employers,provided Nntuch improvements are not Intended moffaM for Asia If, 303 — ROUGH MECHANICAL
however.the building or Improvement is sold within one you of completion,Ne ownr-
builder .will have the burden of proving that he did not Wild or Improve for purpose of 304 - ROUGH ELECTRICAL.
tale.).
C3 I.as owner of Me property.am exclusively convecting with licensed contractors n 505 - FINAL ELECTRICAL
construct the project(Sec.7044,Business and Profusion Code:)The Convector's Lb 507 — FINAL PLUMBING
canmeLaw does not apply nanowner ofproperty who Wilds orimpmmMaroon,and, 508 — FINAL MECHANICAL
who contracts for such projeelo with a coniracmr(a)licensed pontoons Bre
no Cnuaenh o
License Law. j(yJ'yi!-v
❑lAn,exempt under Sac, ,B&PCfro this moon r�y
Owner Date Y/
- WORKER'S COMPENSATION DECLARATION V '
1 hereby affirm under Penalty of perjury one of the following declarations: y
I how and will maintain a Ccnific4m of Contin to self-Wtare for Wohera Compen- V
-.tion,u provided for by Section 3]11(1 of Ne IoW,Code,for the performance of the
work for which this permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as Acquired by Section
311ID of NC labor Code,for do Performance of Ne work for which this permit is Issued.
CY Wr Ara C passel' Ce Insurance d Policy umher tie:
TIFICATEOF^%EMP770 WORKERS' —�
COMPENSATION INSURANCE
(Thu secdon read nothecomp cual If Ne permit tormea hundred dollars(S100)
or less.)
1 certify that in Ne Performance of the work for which Nn permit is Issued,I shall not -- _ - - -
employ any person In any mannerm as m Wrome subject o Ne Workeri Compensation
IA..of California.Dan
Applicant
NOTICE TO APPLICANT.If.after making this Cenifiam of Exemption.you should -
Wrome subject in the Worked ComPenAsilon provisions of the Labor Code,you mut
O forthwith comply with such provisions or this permit shall W deemed revoked.
r
51 CONSTRUCTION LENDING AGENCY
[.r I.N. I hereby affirm that Nen is a construction lending agency for the Performance of
lYi
the work fur which this permit Is Issued(Sec,3(141.Civ.C.) „
WM Q corrects Nuoc //T\
Z conderi Address
V Q 1 comfy that I haw read this application and slob that the show Information Is
0 cording 1 agree n comply with all city and county eminences and tie t lows r upon
lex
p SV' buiwa-meonnsuctlogand hembyaulhon purposes. lire of this city to enbrupnn Ne
W ahovc(We)A=1.sa yfor demnifyInspection Purposes.
W lade)agree n sere,indemnify and kap harmlw Ne City of Cupertino agarol
N IlIts, ments,cru And expenses which may In any way accrue against amid City
V AUNDERSelpeT n DS AIND WALL COMPLY WITH ALL NON-PO Issued by: Date I/
u
-I Re-roofs
gntuue of AppliartlComrscior Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applium m future building occupant non m handle huaNuu material
em defined by the Cupeninn Municipal Code.Chapter 9.12,and the Health and Safety,
Colic.Section us32(.)y All roofs shall be inspected prior to any roofing material being installed.
El Yes / �No
Wtll the applicant or future Wilding occupant Asx equipment or devices;which If a roof is installed without first obtaining an inspection,I agree to remove
it herardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
suit'?
❑Yea P6—.
1 haw mad the hu ndout materials requirements under Chapter 6.95ofNeCalifor-
niaH.0 Cade,Satimw2.5 ,25533and 25534.1undersiend Nsif Nc Wilding
eat mol cu ew a moan', is my nsPonsibiliiy m nnul mcupani of Me
reporemcn hie a Wme ' rnisommen.faCenific a army. Signature of Applicant Date
w reu'hom<degenl Dan All roof coverings to be Class"B"or better