02100025 CITY OF CUPERTINO
nuu.mNc DtvtslorX PERMIT CONTRACTOR INFORMATIONi
Buu-1 -10310DR PERMITN(02100025
owpp7Rlq 1�1I:SN HAMER APPLWAT'l(1� 9,3A 2002
ONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
{O^u00
LICENSED CONTRACTOR DECLARATION
z`OF Iherchyaffirmthat lamlicensed under provisions ofChapter 9(commencing REPLACE FURNACIe)/la'SSIphofIc
Z with Section 7(a))of Division 3ofmc Busi c.sand Professions Code,endmylimnse is
r^6m failforcecif 1. ,# OZ �I
CZ�Z fa class O�I.i- p,� /p
CZ— [ � Cour ri_RfTf_U Leo
ARCf IITECT'SXr ARATION
e.0w� I understandmy plansshall he used as public records
3LLG Lieenvdprofmxinnal OCT 2 12002
oy'O OWNER-BUILDER DDCLARATION
ce a<E I hereby affirm that 1 nm exempt from the Cuntracmr'x I,Icm.w Law fur(he QQQ•]O O O
—00 following reason (Section BUIL ,k�N
$ which requires a permit to construct.alter,improve,demolish,or repair any structure u
prior o its issumm,also requires the applicant for such permiuo rile a signed statement
$�p�< that he is licensed pursuant the provisions of the Contractors License Law(Chaplet 9 3A AAt0t0 Valuation
a S (Monomial ng w It Section 70(1 al Division 3 of the B miness and Professimvc Code)Or '
y duet he is exempt therefrom and the hasis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty Of 3 WN-1,19WPHOccupancy Type
not more than Bvc hundred dollars(g500). P Y YP
❑L m owner of the property,or my employees with wages as their sure compensation, 303 — ROUGH MECHANICAL
will do Ne work,and the swctum is not intended or offered for sale(Sec. Business 3 64
p( g pGpB�,(�
and Professions Cc a:The Connor's License Law does not apply to an owner of 5 0 5 - FINAL L L`l.. 1 eglons
property who builds or improves themon,and who does such work himself or through his
own employees,provided that such improvements are not intended oroRcrod hostile.If. 507 — FINAL PLUMBING
however,the building or improvement is wild within one year of completion,the owner- SOS — FINAL MECHANICAL
builder will have the burden of proving But he did nut build or improve for purpose of
.to I
❑1,as owner of the property,am exclusively contracting with licensed convacmn to
construct the project(Sec.70al,Business and Professions Code:)The Combat Li.
enec law does not apply to an owner of property who builds or improves Hereon,and
who contacts for such projects with a cod ractor(c)licensed pursuant to the Contractor's
Li cnu Law.
am crept under Sec. .B 6 P C for this renin
net �� oamj�—b 2'b
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worlaw s Compere
anion.m provided for by Section 3Rp of the"Me Code,for the performance of the
work far which his permil is issuer.
❑I have and will maintain Worker's Compensation Insurance,as required by Seclinn
37M of the Lahr Cmle,for the performance of Ne work for which this Permit is imucd.
My Worker's Compensation Insurance carrier no Policy num ler are:
Policy N _
CERTIFICATE OF EXEMP I RKERS'
COMPENSATION INSURANCE
(This mesion need mo be complemd if me permit is forone hundred dollars(Slip)
or loss.)
I certify that in the mdo.ance of tl¢work fm which this permit is issued,1 shell not
employ any rsononpc a m�tnerur6s 1pMcpohp�suhjcctto the Workers'Compensalion
Laws of Ca i c I sk' I .
Apprc I
No E TO APPLICANT:If,after making this Cenilicmc of Exemption,you should
hoc me subject to the Worker's Compensation provisions of the lahm Code,you most -
OO forthwith comply with such provisions or this Permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
I herebaffirm
(—� .�. y that more is a Conswnion lending agency lin the performance of
ai the work lot which this permit is issued(Sec.3(1 Civ.C.)
Lender's Name
Z Lender's Address
V 0 1 cenify that I have read this application and Stam that the above information isCOOCCt
0 U Militi.l Agree Constriction,
comply wire yimull yand rounty pocamuinances and city
to warclmingm
me
0 U mOvenmeanoned Mo,nnl hercbyawhorircrposesenmtives of Nis city mentor upon the
w ahovo-me judgments,
udgdproperty for i expenses
purposes.
t.1.
(We) give to save,indemnify and keep harmless the City of Cupertino Claimed
Uh Iiacomcsjudgme the grstsang ex this pawhichmayinsaywayaccrue egaimt seiJ City 1
U APPLI quenee ND granting rein permit. 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUp S.
Re-roofs
SiRgum oppicaRDac
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant slam or handle hazardous material
m&I,C by Ne Cupertino Municipal Code,Chapter 9.12,and the Healre and Safety
C.,&
OJe.Seniors 253321a)'! , L All roofs shall be inspected riot to an roofing material being installed.
0Yes �INo P P Y 8 8
Will the applicant or ffut_ure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hueardous air contaminants as defined by the If
Arca Air Quality Management all new materials for inspection.
District? /
❑Yes
IhavereaJ Nc harallousmumrialsrcyuimments under ChapmrfiJSofine Caldru
nits have
mad
hanrdoum ateria,35533 and nos n.1 under
used 95 f the
building
Joos currently have a tenant,mm it is my reipsmibility m not me ca,up.,of me
.mn which must be mel Primm l:mance ofaCemficam of bhp y. ignature of Applicant Dale
owneroranthormcdagent ate All roof coverings to be Class "B" or better