03030068 CITY OF CUPERTINO + � T"° """
BUILDING DIVISION PERMIT ,� ! ,' "' "X ,�; Ta
BUILDING ADDRESS: _ AAA FURNACE & AIR CONDITIONING•
,
3901 COLTIMBITS A17
2 PERMR LSU
OWNERS NAME: 1712 STONE AVE
NICHOLSON J
E' (408)293-4717 SANRARYN . LNG.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
O O
LICENSED CONrBAC OR'S DRCLARATION Job Description
1 bcmby affirm this 1 sin becu sed under previsiam of Chapter 9(commencing
with Section 7010).1 DIAM003 of ft BumMea and Prefesaona Cede,and my lkeah MAR 2 4 .2003
bLicbnan11 f— o uew� .7 CHANGE FURNACE; ADD A/C
enao ts en, 0.
1 conflaince
Dau ARCHITECrSDECLA N
I underwnd my plan MMI be used as Public records BUILDING .
Lid Licensed Professional
OWNER-BUILDER DECLARATION
1 bemby affirm that i am exempt from W Comnnoes License Law for the
n o following mason.(Section 7(01..1,Business and prefeedon Cade:Any city or county -
122 S2 which mqulms a permit to mmmncl.titer,Mp=ro.dunolith.or repair my someone
prior m its issnncc ala re uira lic ippllemt fm Mich Permit 1.file a signed mu rant
jb< than he is licensed pursuant u the provisions of the Conlredots License Law(ChaPter9 Sq.FI.FIQOr Afee 118t1On
(commencing with Settion700o)nf ,bislon3oflhe Budms.and Pmfcations Col0a,
that he is emmpl therefrom and the basis for the alleged aemPBon.My violatfm of
Section 7031.5 by say appileaml for a permit subjects the applicaml to a civil penalty Of 39ft1lfwnjg 00 Occupancy Type
.at come than five hundmd doltsn(k500).
❑I,as awna of the property,Or my employes with wage an Wn into ampcnadon. ttnx
will do the work aneI
d the 1,ml lnunded or offered foruk(Sec.7061.Bushras — ROUGHRP WNRI*ebttons
and Pmfeadea code:The commences Lkeme law den not apply to an owner or h+
pmpeny who bunds or Improve,Wmagand who doe.such work himself m through his 303 — ROUGH MECHANICAL
own employment,pmvided that inch improvement Lie not immured or offered far wc.If. 304 — ROUGH ELECTRICAL
howerot,the building m improvern=t is sold within one year of completion,the Owam.
builder will love the hold=or proving that he did nal bald or Improve far parpae of 505 - FINAL ELECTRICAL
ole')' 507 FINAL PLUMBING
❑1,as owner of the property.am inclusively contracting with tieenaee antnda,u -
contract the pmjea(see 7044,Business And Profession Cade:)The COntnemfa U. 508 — ,FINAL MECHANICAL
ansa law deal no,apply ban owner of property who b ilda or Improves Wrenn,and,
who contracts for such points with a contract")Iicemed punaant be W Cow w. .
Lkena law.
❑l am nampt under see .B k P C for this mean, - -
Owner rata .
WORKER'S COMPENSATION DECLARATION
I hereby of are under penally of pillory am.of W following declarations:
have and will maintain a Cenifmeau ofCOnanl u alMuum for WMIXeaCarolina.
Moon,it Provided for by Section 3700 of W labor Code,for W performance or the '
work for which this permit b hinted.
1 baro and will maintain Worker's Compensation Insunec,M,required by Seldom
00 of the labor Cade,fared penmmmec of the work fmwhich this permit Is fined. -'
My Warker',Compensation lnsunnce earlier and Policy number am: L
Cama:�`/—a�fi-/✓AO✓ PoIIry No.: 417
—�
I.CKII c, 0,..Pr10NF obi WORKERS' ,
COMPENSATION INSURANCE
(7hnt Made need nol be cnmplesed If the perm 1,is force hundred doll m($100) -
nr2ss.)
— 1 ee dly that In the Mtramane of the work for which thts permit is Issued.I shall am
employ NY per=n in any m!M k�omuubJet to W Warsaw Cmmpemaden '
Laws of Ctlif I Data
Applleenl �--
NOTICE TO APPU�aMr mIng tris Cenifratc of Excmpuon,you,hwld
become Subject u W Workers Comps Ilan powisimu of W labor Code.you MOM
.,O forthwith comply with such provisos O,this Permit Mali be deemed mooted.
CONSTRUCTION LENDING AGENCY
f.mI hereby anWW
rtm lm b a connection lending.geney fared performance of ,
p:
he
murk for which dab permit Is Issued(Sec.3097,Civ.C.)
W Q Lend.ea Nemo
z laedefs Address -
U O 1 certify that I haw mad this application sed sum tied W show inromede I.
carred.l ogre m amply with all city and county omiwrcns and,tau laws mlering to
buildingeoa green anm,Inde authona mpreanuavu of this City to mono agar Orion inst�.t W ..uvmmandaned ProPc_far inspection purpr a,.
g�
(We)agree u Mw,indemnify end keep humlw W Gly of Cupertino split /n
FwN in consequence
r theemntand of this expenses which may in any way accroe agslnn Mid City
C)
APPLICANT
UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULATIONS,
Re-roofs
Sitruens of ApplicmnCommular Dataof Roof
HAZARDOUS MATERIALS DISCLOSURE Type
WIII W applicam orfuture balding acupwaslme err handle haanlow maunJ -
ld-O�wncr
defined by W Cupertino Municipal Cade.Chapter 9.11,and W Health and Safely
Mo.section 3533$.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
WIII W applicant or future balding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove'
It hammaus nit contaminants u dented by the Bey Area Air Quality Management all new materials for inspection.
vict7
❑Yc. u
IhewreadWhazam smaudabmquimments under Chepur G95ofWCalifor
Health&safclyCa4.5rctiom 25505.25577 smI2553/.iundcntsnd dtstlfW yalWing
m not currently haw a Mm=l Nu It is my responsibility u nudfy the necupat of W menu'which run'J/b/e/met prior a issuance of a ecninaM of Occupancy. Signature Of Applicant Date
iso03� All roof cover ngs to be Class "B"or better
Lir authorized spent IAM