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04020093 (2) r CITY OF CUPERTINO , "` "' BUILDING DIVISION PERMIT ,`RONTRA�TOR INFORMA'PION� - ' BDILDINGADDRES: A fa[ II HEATING PERMR14020093 '7425 DR plag OWNER'S NAME: PERMITISSUB DATE 40 ONE: SANITARY KO. CONTROL N0. ARCHITEC YENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH +=sop LICENSED CONTRACTOR'S DECLARATION F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description with Section 7000)uf Division 3af Ne Business and Professions Code,and myliccns is is ran kms and 'qarks} mon" REPLACE FURNACE N swill Lic. �: pp �Qu� oal nHFO Date ARMcl-S DECL d 1 undenund my plans shall be used ss public records FEB 2 3 2004 3 tao t; Licensed Professional 3OWNER-BUILDER DECLARATION n.e 1 hereby affirm Nal I am exempt from the Comment's License Law for the lir/��p ®�� =O following reason.(Section 7131.5,Business and PmRcsiom Code:Any city or county L 9G 12 9 which vaqueros a Permit to com ueL idler,improve,demolish,or minor any structure FIs prior m its issuance.also rrquirea the applicant for such permit m file a signed statement Nrs at he is licensed puuu anotbe previsions of the Commemes Lenten law(Chapter 9 sq. Ft. Floor Area Valuation ,FO Commencing with Section 7000)of Division 3 of the Business and Pro(canons Core)or y that M is.umpt therefrom and the basis fm the alleged.wnpuon.Any violation of Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of 3.0 II19t1111*gt0 0 Occupancy Type not mom Nan five hundred dollars($50Of ❑I,aowner of do,preiremI,or my employees with wages as their some compensstlon, will do me work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions CodContractor'sm e .:The License Law docs not apply an owner of q P property who builds or improves thereon,and who does such wart himmilf w through his own employes,provided that wch improvements are not intended oroRemd f invade If, however one building or improvement is sold within ane Seas of computier,the owner- builder will have the burden of proving dist he did net Wild or improve for purpose of sal..). ❑h as owner of the property.am exclusively contracting with licensed coneracmrs to construct the project(See.7B .Buidness and Probcamons Code:)TIIe Connaebfa L1- crosc Law des not apply to an owner of propeny who builds or impmms thereon,and, who contracts for such projects with a contracmr(s)licensed pursuant to N.Coneracto's License Law. ❑1 am exempt order Sec. .B&P C for Nis mason at Dau WORKER'S COMPENSATION DECLARATION I hereby affirm under Faulty of perjury one of the following decimations: 1 haw and will maintain a Certificate of Consent to milt-insure for WorYCYsCompm- ion,m provided for by Stiction 3700 of the liber Code,fm the performance of the ork for which this permit is issucd. B'rhave and will maintain W9rler'x Compensation Insurance,as requited by Section 3700 of Ne labor Code,fix rhe performance of the work forwhich this Permit is issued. My Worker`.Compenstorinlnsunnee earier and Policy number are: '7 Cartier. 1 �.J 1 Policy No:MIO 2PV 7 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thisseetion need not be completed If the Permit is Forane hundred dollars($100) or lees.) I certify that in the performance of the work for which this Permit is issued.I shall not employ any person in any manner an as to become subject in the Workers'Compensation Laws of California.Dale Applicant NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should become subject th the Wmker`s Compensation provisions of the Labor Code,you most Z forthwith comply with such provisions or this Permit shall Ec deemed mrnkcd. ZO CONSTRUCTION LENDING AGENCY E'4 I hereby affirm that Nem is a eommuctinn lending agency for the lcrformance of - > dm..,it for which this permit is issucd(Sec.3097.Civ.C.) Ula lender's Namc Lendee's Address z U 0 I certify Na 1 haw sad this applicadon and silo:Na ft above inf mumu.is Lt. E-' CmmCL I agree to comply with all city and county ordinances and sae laws relating in DU building convection,and hereby amhorim mitmsentatives of Nis city to enter upon me C shove-mentionedree property for inspection purpoxa (We)agto save,indemnify and keftaP harmless City of Cupertino against FN Liabilities,judgments,costs and cxKnns which may in my way active against mid City in m`the Staining of his KmOOL. U Z APPLICANT eUNDERSTANDS tAND WILL COMPLY WITH ALL NON-POINT Issued by: Da I SOUR TIONS � aaC 7--1 2_—,CA( Re-roofs Signature o Applican/Commucmr Date HAZARDOUS MAT RIALS DISCLOSURE Type of Roof Will the applicant or home Wilding occupant mom or handle havudous material as defined by the Cu"Tho Municipal Code.Chapter 9.12.and the Health and Safety Code.Section 25532(a)7 All roofs shall be inspected prior to an roofs material beim installed. El Yes I3� P P Y g P, Will the applicant r future building occupant use,equipmanordevices which If a roof is installed without first obtaining an inspection,I agree to remove mit hii.oh us air contaminants as defined by me Bay Arca Air Quality Management all new materials for inspection. Digne'? Yes [{M T I have mail the hvarch usmaledals requirements under Chapter 6.95 of be Califor on Hcadh&Sac yCock,ScctionQ5505.25533 and 25534.1 undromnd thmif ds building docs nor curnormly hove a u .m,Nat it is my responsibility m mor,the axupml of the requim^�L which melpmt w' cc o(s Ceruncau:ofoccuponq. (.� Signature Of Applicant Date 1s� ;'�`i Z�Z �� All roof coverings to be Class "B"or better Owner titawlimc.d ngcnl Dat, Community Development >� 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408)777-3333 �UPERTINO Bui11 cd,in g De artment JOB ADDRESS PERMIT # ©DC7 ZOO C 3 -7 _ C OWNER'S NAME: PHONE # 61-f Z 79-e!!> 77 CONTRACTOR: FAX # I am not using any subcontractors: �� Signature r Date Please check applicable subcontractors and complete the followin information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile �— Owner/Contractor S ature Date 10/28/03 2 3 4 5 7 g ,gym'-m' 32'-m" 32'-m" 32'-m' 32'-ON � 32 -01 � T STA I R rN8 LE S2 8 S (E) LOBBY V. 8 (E) "' STAIR XL (E) R CORRIDOR 0 N 0 3 ErvED NOV 1 120 By_ (E) s MEN WOMEN STAI -� r(:D000 na } 3•� �w�v-�or S'l-e+�al� �aiSa�L �e f P OFFICE COPY R VA is s �+' ' cha'6?S. itotiss �. o� aci i 4� 'fib•;_ . jNe; 'A s e 1 1