00030072 CITY
DIVISION
ITY OF CUPERTINO PERMIT CONTRACTOR INFORMATION:
BUILOINGADDRESS: PERMD NO.
OWNER'S NAME: APPLICATION SUB DATE
HONE, SANITARY NO. CONB'ROL NO.
�00 ARCIII'IIECIENGINEER: BUII.DINGPIRMITINPO
mow— BLDG ELECT PLUMB MI�CH
N G Irl I= CJ L:in
NN
LICENsrn colvrRAcroli•s DI:eLARnru)" Job Description
O m C I hereby antro roam 1 am Ileen,ed undo pr,kJots of Clualuer 9(,onmmacing
Fytw with Section 7(Mq)of Division 3 of the Business and Proksdom Code,undny license
ixirmlrnre and tic
REPLACE FURNACE
a o 6 I:mense I. , 2 0 'rax o 0
3 w y )are ,.`L S/sao conlmchr .
ARCI 111'He'1"S DEC C O 4 I und...food my plans shall he used as public mcmdx
i
IC o O Licensed Profcsximad
OWNER-BUILDER DECLARATION
I hereby chum that I ran exempt from the Contrictar'x License Law for the _
G ¢ Rdlowinrrcmon.(S,fon 70.31.5,I1....w,and Rvfcssions Code:Any ray,county
P � which requires a Isomer to construct,alter,improve,demolish,or repair any slructure
ar' a3= prince its iaumice.olso repaint,the applicant for such peminn file a signed document -
Iharheisreensedpnnuanttnthepno immefda,Contmetne,LloemcLowclutpm,9 - Sq. Ft. Floor Area Valuation
(commencing with Section 7WD of Divirion 3 of the Business and Professions Code)
er that he Is exempt Iherermm.,,it the hmis Liv the uttered exemption.Aoyyiolelion '
elSeclinn 7031.5 by arty upplieam for a permh suhjcas the appllcant In a civil penalty
ofamt mare than five hundred aamrs(s500), APN Number Occupancy Type
o I,u ownerofthe propertyonnY employees with wages axtheir sale compensation,
will do the work,and the wore ure is not iaanded or offered for sale(Sec.'AHi. ..� ,g
Bovines,and P...IcWuris Cndc:Tru Contractors License Law does not apply Ice an Required Inspections
r of property Who huims nr improves therdux such and who dsuch work himself -
owner
his own employees.provided that such improvements am not imenmed or
offered far sale.If.hxxwexer,the handing or improvement is sold wid in one year nr - 301 — ROUGH PLUMPING .
completion,the ownembodder will have the burden ofproving thathedidom build or 303 — ROUGH MECHANICAL- improve forpurtunc nrsalul. ' I '
I
El 1.asowncrofthe prolsorty,am exclusively contracting aidi hernodeantruclurs to 304 — ROUGH ELECTRICAL
con ams,the project(Smm 70,41.Business and Profit,ar.Code:)The Contractor', 505 — FINAL ELECTRICAL
License Law des not apply to an owner of pmpeny who builds or improvesre
Iheon, _
and who eantmetx for each projects wuh a cmnmere,s) Iiccnsrxl punuam to the 507 — FINAL PLUMBING
Coolumor'x Licosa Low. -
❑Iahnexempfandersee. B&PC fin this no,m 508 — FINAL MECHANICAL_
Owner Drax
WORKER'S COMPENSATION DECLARATION
I hereby inirn undei(xeralhy of perjury one of the tull—mil delta ratlons'
.7 I have and will maintain f Certificate Se i of 37M o It sit Labor for Worker's �j
Compensation, as provided for by Section 171.1 of the Lahr Code, for the
111performance anw the work for which this mato is issued
°I rocand will,Coce.n far
h er'e Compensation,,work
m hick ul by mettnn �/
3.W of the Labor Cmur fonbe r Imuncanee rster work for whish this permit is
issueJ.h1y Wnrxki/Yfx Compen.ainn Inmmnce mrricNand I'nlicy�number
_art:
CarrihLT Ip CA (1h 13XGMP�IN'ION FROM WORKERS'
COMPENSNUONINSURANCE
(Thi,section need not he completed if the peril is for one hundred dollars
1$1blll or less.) '
I certify that is the performance of the work for which this permit is Issued,I "
shall nor employ any person in any manner so as to lumme,subject it,the Workers
Compensation Lsv,a of California.Dam
Applicam
NfG CE TO APPLICANT:11;aper making this Certificate of Exemption,you should
become subject to the Worker's Coo"r o tan provisions oI Ihx Labor Code,you omit
z Q forthwith comply wish such provision,orde,pumhim shall he deemed.—ked.
FCONSTRUCTION LENDING AGENCY •
ai 7 I hereby of on dualism is a conemerm lending agency for perternmace
w of the work for which this permit is issued(Sec.3097,Civ,C.)
Q Lender's Name
I cuder's Address
V 1 certify that 1 have read this application and state that the above information is -
fi f~
correct,I agree to comply with all city and county urdimance,and state Iawx relating
V mhuild'ugconsmmator;and hereby awherim mptosenunives of this city to crier upon
} �] the above-mentioned property for inspection purposes,
[. L (We)agree to save,indemnify and keep harmless the City of Cupenino against
h liabilities,judgments,costs and expemxs which may in any way accrue against said
1.7 i City in consequence of the granting of this permit.
so Issued
IIJ1D1�u ryrsA/9�3 W95�ILL COMPLY W§H Nrf O POINT ISsned by: DBICqz
^✓ —
Sigmaurem(ApphcahNContmcmr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will Ire app team or future building occupant store or hnmlle hamrdeu.x inaterial Type of Roof
n+delincd by the Cupertino Municipal Code,Chapter 9.12,rul m,Health it Safety
Calc,Steelton 25532(x):'
❑Yes ) All roofs shall be inspected prior to any roofing material being installed.
' Wiiltheapplicantorfwarebuildingoccupantnsenlaipirmtnodeviceswich If a roof is installed without first obtaining an inspection, 1 agree to remove
,it heralded,air batami matt,as defined by the Bay Arca Air Quarte ly Management
Dixmc'? all new materials for inspection. Applicant understands and will comply with
Cyr, " all non-point source regulations.
1 have read the h tmolou.materials requirements ands,Chapter 6.95 of the
California Health&Safety Code,Sections25505,25533 and 25534,1 undershirts]that
ifmhe buildlrg doe.am eonerly have ateraa,Nal it my.........hint,to notify she
mcuponh of the regmre r, fah must b. t prior to isoh nce 1'a Certlficute of
Occupancy.
Imo Signature of Applicant Date
Owrertrammi agent 7 / Dade All roof coverings to be Class `B"Or better