02110063 CITY OF CUPERTINOg
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION `
BulUP0bA1)1zRsSS FOOTHILL BLVD AAA FURNACE &raAIR CONDITI NIf11G02110063
owl@MNviriTONY S AND MELISA S 1712 STONE AVE APPLICATIP1IS W2002
Is I IIONI:: (408) 293-4717 SANITARY NO. CONTROL NO.
ARCIRTECPIENGINEER: BUILDING PERMIT INFO
jEO PLUMB MECIID
�00 LICENSED CONTRACT'OR'S DECLARATION L;%,' ItJO J]tIlI hereby affirm that I am licensed undo previsions of Chapter 9(semmeming UNACE) ADD 2 �Owith Scctinn7(XXp of Division Sof Ne Busine, and Pndesmorts Code,and my license is r'ZOf3 in full foBox I. Uj Z I neemu I [O ) r,Lie.Tl
ARCHITIiCTS RA'f O
Yiy C I understand my plana shall be use ublic recmdx
Oybe U
F G
iLicensed Professional
OWNER-BUILDER DECLARATION
<x I hereby affirm that I am exempt from the Contractor's License Law for the $4000
14a j following mason.(Section 713 L5,Business and Professions Code:Any city or county
Bas$ which requires a remit or cominacl,eller,improve,demolish,in repair any atrueture
Fz< poor to its issuance,also reyuiresthc applicant for such permiuo file a signed statement ssAGS
££ss That he is licensed pu..atI.hepmvisiotuofineContff�� ..AA nchu,xLi...Law(ChapterY Pl laf AaQ Valuation
N a'$ (commend ng with Section 70(c of Division 3 of the Business and Professions Code)or
Nat he is exempt thcmfrom and the basis for the alleged exemption.Any violation of
Sredun 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of PNN Occupancy Type
not mom than EW hundred dollars($500). 30 3 - RO GH MECHANICAL
❑ Lu owner of the pmpeny,or my employees with wag"as their able compensation, 304 .1
will do the work.and she swetum is not intended or offered for sale(Sec.70414.Business ��y
and Professions Code:The Co boner is License Law does not apply man owner of 505 - FINAL RI�tiIIpeAtA n5
property who builds orimproves thereon,and who doesswh work himself orthrough his
own employees,provided chat such improvements arc not intended or offered forade.If, 507 — FINAL PLUMBING
however,the building or improvement is Bold within one year of completion.the owner. 508 — FINAL MECHANICAL
builder will hive the burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively compacting with licensed contncmrs to
construct the project(Sec.7Ma,Business and Professions Code:)The Contncmr's Li. ,
cense Law dors not apply to an owner of property who builds or improves Neeson.add
who contacts for such projects with a contnctor(s)licensed punwm to the Conoecmr's
License Law.
O l am exempt under Sec. ,B or P C for Nis remun
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate or Consent to self moure for Worker's Cont
7031.0x)
line.as provided for by Section 37M of the Isbor Crake.for the performance of the
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Second
of the Labor CMe,for the performance of the work for which this permit is issued.
y Worker's Compensation l summit,carver an Policy mfa amr,icr. I No.: u d 1
CERTICATE OF 'X I NPTtDM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed if ted p<mtd is for one hundred dollars(510(0)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any mannay so a in become subject o the WorkersCompensation
Laws of California,Dale
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicam of Exemption,you should
become subject to the Worker's Compensation revisions of the Labor Code,you most
OO forthwith comply with such provisions or this permit shall M deemed mined,
z CONSTRUCTION LENDING AGENCY
[—I4 T hereby affirm Nat there is a construction lending agency lits the performance of
lX 7 dte.,it for which this pends rs issued(Seri.3097,Ctv.C.)
aLender's No
z Lcndcr'a Address
U O 1 certify Nu I have read this application and state Nal she shouts information is
nmect.l agree to comply with all city and county onirancen and sure laws relating to
O U building eonrrowd(n,and hereby authdrine representatives of this city to enter upon the
W ahovnmentinned property for inspection purpoxes.
11 (We)agree to save,indemnify and keep harmless the City of Coronion against ��
to liabilities,judgments,costs and expenses which may in any way acerae against said City ppp I
U z in consequence of the growing of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date V
/s//
SOURCE REGULATIONS.
�-� I/// . ✓ how, Re-roofs
Signature of pplicandCo ores D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oseupanl store or handle hvatioue material
res defined by the Cupertino Municipal CMe,Chapter 9.12,end the Health and Safety
Code.Section255321a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Ycx tNo
Wits the applicant or lure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hanwous e
air conminants as do fined by the Bay Ar"Air Outo ly Management all new materials for inspection.
DNina?
❑Ycx
I haw mad Ne hzraNnus materials requmornew under Chapter 6.95 of the Califor-
du Health A Safety Code,Sections 25515,25533 and 25533.1 undersexed Nat if the building
docs not curnlly haw a unank Nat it is my responsibility us nod ly the occupant of the
requirements which must he mel prior to issuance of a Certifich 'w aney. _ Signature of Applicant Date
it.nm nr authorized agent Dale All roof coverings to be Class"B" or better