02010116 CITY OF CUPERTINO `
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION-
BUILDING ADDRESS: PERMIT NO.
21782 LINDY LA CONDITIONED AIR 02010116
OWNER'S NAME: APPLICgTION SVB DATE
NOLAND WALDO M AND SYLVIA D 164 B GILMAN AVE 01/29/2002
0 PHONE: (408) 374-6311 SANITARY NO. CONTROL NO.
°�+O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
E'w BLDG ELECT PLUMB MECH
CUl I-U L_7 L�
LICENSED CONTRACPOR'S DECLARATION
$y i hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
withSection70M)ofDivision3oftheBusinessandProfessionsCode.andmylicense 120, 000 BTU FURNACE C'HANGEOUT 5 TON AC AD
i O m5 is In fall force and effect.
U License Class Lic.Y
Date Contractor
0 ARCHITECT'S DECLARATION
c- .Y 1 understand my di ns shall be used i s public records
�
ww p p Licensed Professional
E. OWNER-BUILDER DECLARATION
M. 1 hereby affirm that I ora esempt from the Contractor's License Law for the $5300
t?a following retrry
act.(Section 7031.5,Business and Professions Code:Any city or coun
° which requires o permit to construct,alter,improve,demolish,or repair any structure
a3� prior m its issuance.also aquimthe applicant for such Permit to rile v signed women -- -- --
,hat he l;licenxd ;a Can td Ne pao"oroafthe the and tors Limnx hWaa,C 1.) ms` s �.a,FtroprOyr- y�eea. Valuation -
(commencinBwi,h Stttion,70W)of Division 3 of the Business aad Profession Ctrdel 7''f !`;u".3�g2vy(IL,r,..®V s•«j7'I-td
or than he li eiempr Iheicfroin end the basis for
the
al@g<tl eaemp,ion.Any viole,ion -t•.'l' }i>r;
of
Section]031.5 by any applies',for a permit subjects die applicant to v civil penalty
tof
no,more than live hundred mnar.(Ssoo). 301APN h.1tJFkm PLUMBIN Occupancy Type
❑l as owner critic ppony or my employees with wages as their sole compensation - -
'-wtll do,he walk,and'he structure is not intended or offered-for sale(sec 70JA,- -- --- -" -- - ---
towner or pro Profen Coda The Contractor'ssteno ,and w Law does not apply m an
304 - ROUGH EEGQ-SI1Bd0Djfactlons'
owner of properly Who builds or improves thereon,and who atref such work intended
or 505 - FINAL ELECTRICAL
or,h gh h n employee.. provided,-o, h improv nems arc ,intend J or _
-Fblf edf ate he owner-builder
rthe will building-ort - p (if
IJ within'o a tri of "---'-'
,'507""'-"- FINAli PLUMBING .; >. ..,
improvcon"Ice turposer hal.). have the burden of Prov ng that he did not bold or 508 - FINAL MECHANICAL
improve 1'or purpose of sale.).
___._._..__......usiv cont ..__i
. OLaanwncrof,hccontracting-
pmpeny.am Businiss andsions Cade:)
Conor contractors to { [::.; ;;IL
iouLicense the does
project(Sec.7094,Business and Profusions Code:)The Contractor's
License Law day nm apply m an cit& f property who hullo seimprove,hereon,
` _and wh0.ca Lien,s for ouch proJttts iN s co trector(s) cenud pursuant io(tie._... _, .__
01 mnols pt'nse Lew
❑lam esemp,under Sec'' "t ',B&PCfor lho reason FBI�A�Eti ti[`Lt,i
Dvner _., ENS APR 0 3 2002
WORKER'S COMPENSATION DECLARATION
.'� 1s..• `I hereby affnn under ,
y pen Try of perjury one of the following dedamuomr
w.
❑ 1 have and will rat Certificate f Consent to selbmeurc for Worker's gVILDING
C pens- n;
its-provided for by-Section 37M of the Labor Code, for Ne
Performance of the w rk far which this pcrout is issued,
J, ❑1 have and aoill mjrinmm Wmke's Cop sen Insurance,as required by Section
37W of,he Linhor Cale,for the perfoimence of the work for which this perrid'is
' is J,My W ker.Cimin,ter6imin I ' r unJ Policy rmddc,a
.,
ca" t v�CER'TiI PICATION OF E%EMPTION FROM
..� ,_.•_,,..:,�_....
,'� CA , .{ -Play ( MWORKERS' t lobo ik Jittd ( � fi t s,
COMPENSATION INSURANCE
- .. .,,. -... ,., row. ' -....... ._ ._.-. .toot. ......
This sit needhad be compated if the permit is for one hundred dollars - "' "`'' "I __--~ "�'•-M{�i" � l� �' ~ '
(SIM)If less.)t_
I oily,h�t n ih performance of th' alk f r Nch the pnrnit iv ins d 1 - � � _�_ r � �, .I -,,. I'.:
shall not employ any
ComfC.1d m any ma so u io'beaome suhJen',o the Workers -'` `'
pensvion Lawof Coli
is fomia.Dae n'
.. .__._. _, -.--- -
['NOTTCETOAPo tbCWokcIf,es Commaking,his6vivmcvm of Lidor om;youshould
tioeome subject to,he Wakels Colons or this provisions of the Lalwr Code,you must
Q Q forthwith Comply with such provisions or this permit shall M deemed revoked.
iZ"`U1 ",,CONSTRUCTION LENDING AGENCY -
l:" t-I hereby (lino that the v con mucron lending agency for the perform -
t ,
of work for which this pe a-issued(Sec. Civ.C)' ......
a. `
A,eQ ' Benders Nand"+ - c a.: :,. t ._ _ _
._ ._._ ..
Q,z 'L nJ tis AJdoes
r, I can fyl c happlication and otao einformation u
c r t l g tin q, m re ply w th all try d county ordinances
ces iW
d m, Ins claim,
V b ild e- i , m hereby a erre oma,- (if this city,to coo upon
'hM
��++ rigis the n ni uneJ property for impecum p rpoxs.
Pis (We)es,judgmeio.costs dnnnifydndk which
Ory accrue
against
said
0 liabilities,judgments,coos andran expenses this
which may in any way ecrue against said
i-' <•:,1Gy CV in'con`ZUNccuf,hegDS'ingohhiipcCO
SOUR CANIL U LATIONINDS'ANp WILL COMPLY WITH ALL'NUN-POIfJTs'
- - soURCE ReeuLAnol4s,,, ,:,!-:• .� ,. Issued by: Date
signature ar Avpuconticommrmrr,t::.'. .. ,�,,iDa��, .:'+'.., Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
r
Wit the applicant a future Wilding occupy store or handle haamdtrue malarial �I e Of Rf -_ ._ ......
:os d Bned by theC penmo Muni c pal Cod Chapter 9 17 and d Health d Safety -`J P oot - - ---f l -""' "•` v- '•�'�� �
Cade Secdod 2553_(a) r f v A 1.( i'>, i 1,11, - sit T••r s P M1{ \
1
.;0 Yet,
( ,, ❑No I - '
All roofs shall be inspected prior tQ any roofing_matenal being installed
\ ,
Will the applicant or future Wilding oc -p niuse equipment ordevices which If a roof is installed without first obtaining an.inspecnon I agree ni