02100129 CITY OF CUPERTINOr
BUH.DING DIVISION PERMIT CONTRACTORAINFORMATION
BDllpl o3EzvONG OAK LA AAA FURNACE IS, AIR COND I T I N T41IM 210 012 9
1
Wn71t QA&BS MILTON AND ROSE 1712 STONE AVE APPLICATITIUPTgY1002
IONS (408) 293-4717 SANITARY NO. 77 �S / CONTROL NO.
ARCHITLCDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEGA
�pp LICENSED CONTRACTOR'S DECI,ARA3'ION
E I herebyaffirm that 1 am licensed under roakkno of Chapter Y cnmmencin ResC ryp�On,
`u5 with Section 70(u of Division 3 of the Business and PrnfessionsGle,and my licenseg REPLACE FURNACI & Hli1J H�L'
D s in full Tome and cffcgp y
License Class C Y P Q Lic,M
ZOLSZ
F$=FO Dam Cnnuactor
gr,E 1 J' R II=C`11DECLA ATI
O U I utdcolund my plans shall be used as public reanrit,
LLO Licensed Pn lessional
Dat I am exempt
D rept fr DEthe ConTIDN
`v 0 I hereby aft that 1 1. exempt from the Cunoanoh License Lew for the $4000
d 6 p a which followingmatch,a.Permit
Section 7onsu Business and Pnrfessit)na Code:A ai city or county
$ which myulms a penlr m ennsaruct,eller,lmpnrve,Jomnllsh,or repair any structure
to
poor to its issuance,alit)requires the applicant for such permiuo file a signed statemcm �a'aa��
that he is licensed pursuant In the provisions of the Contractor's License low(&pmr 9 33r�M20C3a1BA10A Valuation
(commencing with Section 7(100)of Division 3 of the Business and Professinna Code)or
y —
that be is exempt therefrom and the noesis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of PN-N Occupancy Type
Out more than five hundred dmlan fssfnj. 303 - ROUGH MECH ICAL p y yp
❑1,as owner of Use,property,or my employees with wages as their ante compensation.
will do the work,and the structure is not intended oroffcmd for sale(See.7044,Baseness
and Professions Code:The Commctor's License Isw does not apply to an owner of 505 - FINAL E RTKtiOns
properly who builds or improves thereon,and who das such work himself or through his
own emplayes,provided that such improvementsw not intended orolfered for We.If, 507 — FINAL PLUMBING
however,Inc building or improvement is sold within ON year ofcomplenon,the owner- SOS — FINAL MECHANICAL
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
❑1,as owner of the properly,am exchuively contracting with licensed convenors to
colonel the project(Sec.7014,Business and Professium Code:)The Comractor's Li .
Genu Law does not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such projects with a comnctor(q licensed pursuant)the Contractor's
License m Law. �B sy rs
teexempt under See. ,B&PCfa Person �5� ® .
Owner Data
WORKER'S COMPENSATIONDECLARATION OCT 3 1 2002
73E7��)O()
I hereby affirm under Nulty of perjury one of the following declarations:
I have and wil l maintain a Cool Ocate of Consent In self-insure for Worker's Compere
ron,es provided for by Section 3700 of the Iden Cale,for the pedormence of the BUILDING
rk for which this Permit is themed.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of die Labor Code,for the Performance of the work for which this permit is issad.
y Worker's Compensation nsurufcecarrierandPolitynumlerarerder. r�r� Policy No.: 2i 3�Gk 2.-0
CERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if flue permit is forme hundreddollars(SIRE
less.)
1 cenify that in the Performance of the work for which this permit is issued,I shall not
employ any perum in any manner ss as m become subject m the Workers'Compensation
Laws of California,Date
Applicant
NOTICE TO APPLICANT:If,after making this Cca ificruc of Exemption,you should
become subject to the Worker's Compensation provisions of the Ishor Cale,you must
0 Z forthwith comply with such provisions or this Permit shall be deemed revoked.
z0 CONSTRUCTION LENDING AGENCY
[r iii Ihereby.1irm that Nero is a construction lendi ng agency for the performance of
lYi 7 the work l'ur which this Fermi t is issued(See.3097,Ci¢CJ
QLenders N.
Z Isnder's Address
V O 1 cenify Nm 1 have read this application and sum that the above informaion is
I2. F counter,I agree to comply with all city and county ordinances and state laws mining to
pU building construction,and hereby authorirc represturroves of this city to enter upon the
W above-mentioned property lire inspection LoNces.
O. (We)agree to save,indemnify and keep harmless the City of Cupertino against
nFi Vf liabilities,judgments,costs and expenses which may in any way accrue against said City /
U in consequence of the granting of this return. 1/
r4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI.L NON-POINT Issued by: Date
SOURCE REGUI.ATIONS.
Re-roofs
Signature orAppheaO Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building acupam store or handle bvardous mamdal
as dc.L by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety
C
ode.Etyma ss3zla )7 /Ii�'N' All roofs shall be inspected prior,lo any roofing material being installed.
Will the applicamnrTuturoloildingacupantuse equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
•mil hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Goodell poll
1 have mad the hazardous materials requirements under Chaprerri 95 of the Califor-
nia Health a Safety Cale,Sect ons25505,25533 it 25534,1 undemu d Nat dine building
doesnotcurmndy have a tenant.Na it is my responsibility to notify the occupant of the
rq .�enimwhiehmua�t�bem�ap����iiszaanaoraCCrr2ctoafacaPaay. Signature of Applicant Dale
Owner or anotooiacd agent �� /Date L All roof coverings to be Class"B" or better