03100191 (2) CITY OF CUPERTINo :�.,
BUILDING DIVISION PERMITCONTRAGTOR INFORMATION .
BUILDING ADDRESS: t7 & J AIR CONDITIONING PERMIT NO.O3100191
' 9922 FORGE DR EAST
R'S NAME: 1280 N 10TH ST PERMIT ISSUE DATE
OBLIX 10 27 2003
PHONE: (408) 920-0662 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C� t E
±oo LICENSE.DCONTRACTOR dunderSDECLARATION Job Description
Fp I hereby affirm That 1 am licensed under provisions of Chapter 9(commencing P
taW with Scainn tNkq of DivixionJof the Businciv and Professions CnJc,and myliccnu is
mrmlrareto effen.C_Z0 REPLACE 2 A/C UNITS
>�? License Class Lic.N
Date -� 'O COmmnm - A'Y
L ny ARCHITECTS DECLARI ION
C y< kt nderstand my plans shall rte used as public records
anV
o'° Licensed Professional
g OWNER-BUILDER DECLARATION
i<P 1 hcrchy affirm that 1 am exempt from the Contractor's License Law for tM
°0 following reason.ISectiun 71131.5.Business and Professions Code:Any it,Or county
<m which ramrims a permit m mmsumu.aIle,.improve,demolish.nr.Pair any structure $39000
pdonn its iexhance.also requires the applicant for such Permit to rile a Mucd statement
_r<
that he is licensed pursuant nLife provisions orthe contrimmrsucensaLaw(Chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7")of Division of the Business and Professions Cook)or
that he is th
exempt erem froand the bush for the alleged exemption.Any violation of 31609030 . 00
Section 7031.5 by any applicant for apc.if objects the applicant 1pacivilpenaltyof APNNumber O
not more man riOccupancy five hundred dollars ISs00). P Y Type
❑1,as owner of the progeny.Or my employees with wages its their sole compensation.
will do Ne work,and the structure is not intended of offered for sale(Sec.7044,Business
and Professions Cade:The Contvnori License law dols not apply to an owner of Required Inspections
progeny who builds or impm ce thsoon.and who does such work himself or through his
wnemployccs,provided that such improvements are resurfaced proffered fossale.It, t— �11� /1 tt ��
however,the buildingnr improvement issold within one year ofcompletion.the owner- F ��YJ(aLa� {tet
builder will have the burden of proving that he did not build or improve fur purpose of
sale.). JAN
p O q
C] 1.as owner of the property,am exclusively contracting with licensed convectors to J FIN 0 2004
COORMO the project(Sec.7144,Business and Professions Cndc)The Contractor's Li- .
cense law does not apply to an owner of progeny who builds or improves thereon,and A1 p�
who convacs for such projects with a conracmr(s)licensed pursuant to the Convaclors BUILDING License Law. U �W` lG
1 am exempt under Sec. B&P C far this reazon
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRrtn under penalty of perjury one of the fallowing declarations:
7�wrk
ave and will maintain a Certificate of Consent self-insum for Worker's Camped.
,a provided for by Section 3700 of the Labor Code,for the performance of the .
for which this permitis issued.
ave and will maintain Worker's Compenemion Insurance,as required by Section
of the Labor Code,far the Performance of me work for which this Permit is issued.
or/ke�r�'s C1om�pensation Insurance caBicynumrfQe`Tk Lg,nP .it..5 a Icy No.:A CID ��I a{Y/
\ A CERfIFICA OIEUEMMON FROM WORKERS
'
J� COMPENSATION INSURANCE
C unk section need not to completed Bile permit is for one hundred dollars(Sl00)
or less.)
I certify that in to performance of the work for which this Permit is issued.I shall out
employ any Person in any manner an as to hecome subject o the Workers'Compensation
Laws of California.Data
Applicant .
NOTICE TO APPLICANT:if,after making this Cenilicam of Exemption,you should
become subject to the Worker's Condensation previsions of the tabor Cotic,you must
D z forthwith comply with such provisiau of this permit shall to deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conswedon lending agency for the performance of
.Y > the work far which this permit is issued(See.3097,Civ.C.)
t7 Q Lordcrs Name
L
� z Under's Add.
0 1 certify that I have read This application and sus that and above information g is _
S. F wren.1 agree to comply with all city and county miflNts Of and sem laws relating tCJ amovengcanswclton, hereby thoriae«prescmativu rel this city to enter upon Bee
= C shove mentioned P y for i trio pmiwua
(Wet)agree o ve,in c ify d kith harmless the City accrue
Cupertino against
Z ince itie niece s os s d ape swhich may in any way eccrve against raid City
J,'� A con uNT RD gm n tf IM1' pc WILL
'—' APPL ANT DER DS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CER ATI 11 ?w12,2J�
Re-roofs
S App a IA o DOUS MATERIALS DISCLOSURE ste Type of Roof
Will the applla future building occupant Ram or handle howdous material
efined by the Cu no Municipal Code.Chapter 9.12,and the Health and Safety
Suchen 25532ta)?Fl YearAll roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant ate equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit act, us air contaminants as JctincJ by the Bay Arca Air Quality Management all new materials for inspection.
Disvict?
Yes
I have fcadIf a s aliials requirements under Chapter 6,95 or the Cali for
ria Health&S aty ,S d 505,255J3and255J4.lundcrs=dthatif Nclvllding
Uces not cof ntly t at it it my rtspansibility m nntily the fxcupanl of the
reyui¢.a wit mus rte 6.11.iseu riCerifiaakofy p,`a . Signature of Applicant Date
0'3
e aworag All roof coverings to be Class"B"or better
OwnDee