04110156 CITY OF CUPERTINO '« g.
BUILDING DIVISION PERMIT CO, "GA TOR-INFQRMATION BUILDING ADDRESS: FALCONE PLUMBING & HEATING PTIf4tNO04110156
10773 BROOKWELL DR
OWNER'S NAME: PERMIT MUE DATE
AMY MA 650 LINCOLN AVE . 4B ii /24 /2no4
ONE: SANITARYNO.._ _ _ .... CONTROLNO.
(408) 293-5676
ARCHITECTIENGINEER' - - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
nOp LICENSED CONTRACTOR'S DECLARATION Job Description
<wF!� 1 Worry agmm Net I am licensed under Boos' au of Chapter 9(commencing --
n�S wiNSCcrr n 3 of NC Businexi Pmfcssinaz Code.and my fee=is
it ton mree,ana etri G3�' I' 7y0 p,�— REPLACE FURNACE
=
Jj2Lumicclus Lk.N 6
4;:, Dao: Contractor
A CHITECTS D6QL.ARATION
e i 1 un c tE my plans shall be used as uBl IcAsomis
yU y 7/
Z LL G Licensed Professional
5 OWNER-BUILDER DECLARATION /
<l I hereby affirm Nal I am exempt from the Contractors Leon.Law for the
C O following reason.(Sectionss]051.5,Busineand PrefuJum Cade:Any city or county V
K$g� which mquims a permit to cmutmet,alter,improve,demolish,or repair any shocmm - -
m-m Prier to its issuunce.aiws requires theapplicien forsuch Permit to fieasigned summcm _
�s< that he is licensed pumuanito the pmvisiom of dtc Contracture Urs me Law(Chapter 9 Sq.Ft. Floor Area - Valuation
'Ho (commencing with Section 70(10)of Division J of the Business and Professions Com)or " ' -- - - - - - --- -------- - --' -
i that he is exempt dominion and lac bodis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 er0 0Occu ane Type
net tome Nan f.a hundred d.11ars(5500). - P Y YP
❑1,az ownar of tW property,or my cmploym with wages u Heir axle comperavJon,
will Pn Jscwork.Cock: be Cmiisorres LrWaaoraw do fns sale(Sec.70a4,Business
and eny who
Coda:The Contactors License Law aces not apply if m mugh is Required Inspections _
propertywho buildsorimproves ch improvements
andwho doessuchworkhimselfedNmude his
ow ever,the
Wilding
provided inorimprovement Nat such improvement are not intended mo oon.for Owner.
builder theave thgorrovighatIcs sold iiinot Year or mproefor pu owoco-
builder will have the burden of paving that he did not Wild or improve for purpose of
sale.).
. ❑I,as Owner of the property.am exclusively contracting with licensed contractors to
construct the pmjca(Sec 70,14,Business and Profrsaiott Code:)The Contactors Li. -
cense Taw does not apply to an owner of property who Wilda or improvrs thereon,and
who contracts for such projects with a contnctogs)licensed pursuant o the Commentr's - . .. -
Lkcnses law. -
O 1 am exempt under Sec. B R P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby afftme under perulty,of perjury oro of the following declarations:
1 have and will maintain a Cerditaatc of Consent to selPiruum for Worker's Compare
sotion,az provided fm by Section 5700 of the Labor Code,for the Performance of Nc
work for which this permit is issued.
❑1 have and will maintain Workers Compensation insurance.az neprined by Section _ -
3700 of Nc tabor Code for Ne performance of the work for which Nis Permit is issued.
My WorkerseCompen a2fi!!n Ire ssom carte.and Poles number arc:
Cartier. `-'�a'a`/ Policy No.: D 7_7�Q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th'secen. of hecomplcmJ it tie Permit u reform hundred dollars(SIM)
or less)
I certify Jut i5c pe am of the work for which Nis Permit is issued.I shall not
employ any parson it ma A ren to to u +c t MWorkeri Compensation
laws of Ca mini (m
Applicant
NOTICE LICANT:IL afar making this Cenificam of Exemption,you should
become su 3Cct b Nc Worker's Compemation pmvisioni of Je IaWr Code,you must
O forthwith comply with such provisions or Nis Permit shall W deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
PI hereby affirm that there is a conern ction lending agency Tor the Performance of
a ? Ne work fur which Nis permit is issued(Sec.INA.Civ.C.)
W Undoes Name
D' lcndcr's Address
Z) z
U O 1 certify that 1 have read this application and sum the the above inrormadun is
ly Fcored.I agree to comply with all city and county ordinances and sum laws relating to
O U Wilding consuuction,and hereby aotimim ne[esentathes of this city to enter upon the
a Wvc-mentioned proPcny for impaction purposes.
F G ( me ro sa ;indemnify and keep ham less the City of Cupertino against
,,l tiabilitipa.jud cru, uand aapemcs which may in any way agantst said city
UZ in consegmxm ofN ming of this
permit. ' s
^ APPLICA N STANDS A CCOMPLY ITH ALL NON.POINT Issued by: Dale .
SSOUt U
�" ` �i/''Y/"y Re-roofs
Ssgnatum Of APplicandA!r actor /` tDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or for=Wilding oceupantstom or handle he'msrdom material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
made.Schen 25552(a)! All roofs shall be inspected nor to an roofing material beim
❑Yea P P Y g g installed.
Will the opinion,or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit Im,indous it c.Oreco ants as ofcfnc .by the Bay Arca All Quality Management all new materials for inspection.
Disuin?
❑Ycs
I hBvcm chv mornmerials requirement under Chapterti95 ofthe Califon
ria He.IJi&Safc Sciu=25505.25555 and 25534.1 undersand but,ifthe Wilding
Jnea nm cudmna meant and it is ihility m nauly c excupent ofilm
regwre rat a artniaaaananfacrrdfcateaf Opvtey. Signature of Applicant Date
If iy/oa
Dwdm mm�n eaagrn�--� Dom All roof coverings to be Class"B" or better