02100053 crry of cuPeCONTRACTOR INFORMATIOM
BUILDING DIVISION
sH7N PERMIT .. � � .�.
Hen;ng(8k9I&FSCRICKET HILL RD A & H HEATING PERMITN®2100053
� illi ELL 770 CHESTNUT ST APPLICATITIU1 Iyu?2002
ZONE: (408) 279-0722 SANITARY NO.// / CONTROL NO,
RCHITEC MNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
J-00 LICENSED CONTRACTOR'S DECLARATION
t<Lo U 1 nerenr anirm mal 1 am licensee u it r ptomsi ons of chapter 9(commencing Description
�'ua withsecean 7axnnrDmmian3ar leen anJPrnresannscn,le.awmy h«ase is REPLACE FURNAC'
in bell rot dcrfypl._Z
zo�KLicense lass ` I.ie.N
FiFW Dum 'Commcmr
3'y2t:aa ``SS ARCIIITECTS DE TIOI
CyK undccannd my plans sM1allbeuscJ as public raoNs
KO"U
m 3 u y Licensee rrurossnrnal
FLLOa OWNER-BUILDER DECLARATION
gga P 1 naso .(sero that 1 1. exempt tram the Contractors License Law for the $2000
d6p0 wllowingmmx aPen. cction 703 1.5. alter,
and improve.
demolns ish,
Cook:Anycity annoy
$ which tits ices a c,also re vires the aper,i t for
demolish,nr repair any.tatement
�7a
poor it issuance.also requires the applicant Tor such permiuotilcasigned statement
That he is licenced pu mantb the provisions of the Contractor's Limns Law(Chapter 9 3s�2H 'ejb6At0� Valuation
as (commencing with Section 700 )of Division 3 of the Business and Professions Code)(it
y $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit subjects,the applicant m a civil penalty ofIG
not more than Eve hundred dallorm(SSW). PTrN Occupancy Type
303 - ROUGH MEC ICAL
Les me work.
old pmpcny,or myemployres or owagesazale(Sec.r sare 0,14.8 Compensation,
will Jo me work,ane the structure is not intended o Law do for not.(Sec.THC.Business
3 84
and Prty wh obu Code.The Convectors License law deer or apply lf an owner of 505 - FINAL tti 4� 'OOS
property who builds m improves thereon.and who ecenot in work Mmcelredthrough his
howmen ever.meea,pingorided mauuehimpmvemwtthin not dedmnetin.theOte.If, 507 - FINAL PLUMBING
huilder theaveteorden of ement provdshathwithinone year of completion,theose of
sailacr will have the burden orproving that he did Orn ossa or improve for bonbon nr 508 - FINAL MECHANICAL
came.).
❑1,as Owner of the propert,am exclusively contracting with licensee contrdemes to
construct me project(Sec.70a4.Business and Professions Code:)The Contractor s Li-
cense law drcs not apply to an owner of property who Wilds or improves menton,and
who contracts for such pmjecm with a contractors)licensed pursuant to the Contractors
Liccnsc Law.
I am exempt under Sec. ,B&P C for this reason
ncr Dam
WORKER'S COMPENSATION DECLARATION
I hemby aRnn under petahy of perjury one of the following declarations:
I have and will maintain aCerti(cam of Comenuo self-imam for workers Compen- ruaq Aj e
Vl
on,ses provided for by Section 3700 of the labor Code,for the perrnrmanee of the Il 9 v'�
r far whim this Permit is issued.
1 ave and will maintain Worker's Compensation Insurance,az inquired by Section (5 '� 7 2002
of me Lahr Code,for me Performance or the work for which this permit is iaued.
My Wrrtkers Compensation Insunnee tamer and Policy nu
C micr:�[JO6� j ��] Policy No.: OZU ��'q ®'P1�.
CERTIFICATE OF EXEMPTION FRO ORKERS' ILDING
COMPENSATION INSURA CE
(This section need not tecompleted done permh is far one hunthcd dollars(Sla)
v Iesa.)
I Certify that in the Peflorman t,of the work for which this permit is issued,I shall not
employ any person in any manner so as m become subject In the WorkersCompensation
Laws of California.Dam
Applicant
NOTICE TO APPLICA Nr:11:after making this Corti licate of Exemption,you ohou ld
become subject to the Worker's Compensation provisions of the Labor Code.you must
O O forthwith comply with such provisions Or this Permit shall be deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
r: I berchy affirm that dere is a comwction lending agency lar the performance of
CY the work fur which this petmil is issued(Sec.3097.Co,.C.)
W0. Q Under's Name
D z Lender's Address
U O I comfy mat 1 nave read this application and sum that the above hoomation is
gL F comet.1 agree to comply with all city and county Contracts and stole laws relating to
0 U building Construction.and hereby anthoriec representatives of this city m enter upon the
shave-mcminned property for inspection purposes.
(We)agree ,,save,indemnify and keep haralces the Ci ly or CuPcnino against
lin liabilities.judgmenu,costs and expenses which may in any way accrue,against said City
U z in consequence of the granting of this Permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CEREGULATIONS.
�O- Re-roofs
amore al APphcunocnmraamr Dale
IIAZARDOUS MATERIA.S DISCLOSURE Type of Roof
Will the applicant(or future building Occupant store car handle ha,,mmms material
as defimd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
vele,Section 255321x)? -
❑Yes abler All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
strict?
Yus h No
1 have mad the bteonf r,materials rcquircmencs tante,Chapter 6.95 of thc Calif.,
Of.Ilealth&Safety Code.Sections 255)5.25533 sold 25534.1 undcrswd mm if the Wilding
Jnea 00l currently have a Tenant,mat'I ih my 2" am to nobly Ibe nemannl of he
m htmr wmmhmavRmelpm tiavuanecoraC,or orarupancy Signa[ureofApplicant Dale
Owncr n,authorized ager, D„-0 All roof coverings to be Class "B”or better