01110076 CITY ILDING DIVISSIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNO.
10214 MINER PL TAYLOR LLOYD A AND MARY 01110076
OWNER'S NAME: APPLICATION SUB DATE
TAYLOR LLOYD A AND MARY A 11/16/2001
PHONE: SANITARY NO. CONTROL NO.
1
MIM ARCHITECT/ENGINEER: BUILDING PERMIT INFO _
w o 0 BLDG ELECT PLUMB MECH
h i LICENSED CONTRACTOR'S DECLARATION Job Description
5 2_� 1 hereby affirm that I am licensed under provisions of Chapter 9 tcommencing
m l_m wiN Section]11(101 afDivisionJof the Business and Professions Code.and in,license REPLACE FURNACE
C m I� is in full forte and effect.
ne m a License Class Lie.x
0 a u Date Comractw
ARCHITECT'S DECLARATION
0,g 1 understand my plans shall be used as Public mcoms
r
3_z O O Licensed Pral'es>imnal
Oat I an,exempt r DECLARATION
eras= 1 naso.(fors Nm 1 o exempt from the Cessions r'e License Law far the
t?a following ores a permit t ]ommuctusiness and Professions Code:Any city or county $1200
F x O which requires a permit to construct,altar,improve,demolish, file
repair any structure
n3'_` ' thitHeisBemer Initiation
int hi that timesirm for wch permit tLBenseLw:dewremem ---- ----Valuation - -
thommmiicenreit pdrsaann700p fDixinsof doe Ce Burins turad Pe Law(ChapterCter9 e, S t�/Gs�Qp I 4 ValU8Il0❑
or thin i ing wiN Section7000)an l the buisis o t the legedess and PmfA Any
Code) . .�.-5 131 b:V 01.^ 11
or Net he is cxempi therefrom vier(the bans for the olleged"ucmptiori.My violation
of Smion]03 LS by any applimnt fw v permit wbjecn thcapplicant to a civil penalty
n1rnnt�/momohanr nnrmmadnuarsasoo). 30:1PNI��rH PLUMBI Occupancy Type
61as owner of the propen,t or my employees with wages as Ncir sole compensation.
will ne me work.arra me.noun n not intended I-i or re Law does.ale(see:town 3 04 - ROUGH EEM!ttW11(MG
Business amt Professions Code:The Com then a Licence Law tins nw apply to an [1005 `
ownc
r of property Who builds or Improves thereon,and who does such dirk intended
or
or through sal own employees.,budded that wen mprovemrnt,are nw intended or 505 - FINAL ELECTRICAL
bffcrcd fur sale If,hue th buildin tis sold within one-car of .. . _._ ..__... . ._.._.
nniplct tun,the owner bu lder will hove the hunlen of Fussing the,he did not build or 507 - FINAL PLUMBING
improVe for par,ose fes°") 508 - FINAL MECHANICAL
°n,as owner of the property,am exclusivelycontractingFranconian,
with licensed e Contract to
conswn the project(Sec. to a Business and orty who Code:)The Contractor's
License Taw does not apply m an owner with
pmpeny who builds seimpoves Nercm e
and who concocts far intent projms with a mmnctwlp Ii¢nmt purwant to Ne. . _..._. _. ..._ _. . -_ .. _. .._.. _. _ .. ._ _ _ _
• . - Conconors License Law. V 9 0 0.1
Ol am<xe-P under ec' '.BRPCfor this recon �;: „ .'I:.N.O• 9 L I
Owner A✓ "
-:: � C 'S NSATIONDECLARATON BUILDING
I hereby affirm under penalty of perjury one of the following declarations:
A ° 1 have and will maintain a Ccnificum of Conran to self-insure for Worker's
1 Cumpcnsto m provided for by Sectio 37W of the 11, Cade It the
perfonnantt of the work for wM1irh thir permit is ivued.
fl
°1 have and will maintain Worker's Compensation insurance,as retained by Section
37W of the Labor Code,for the perfmmonce of the work for which this permit is
issued.My Worker's Compenmarm Insurance carrier and Policy numM etc .. .._-..,
,.. ) ::{';:711•. r r ).,
Carrier.
.. . -s' .. .:. _ MYNw: s'•CERfIFlCAEXEMPTIONWORKERS"
COMPENSATION INSURANCE:"
•
..
[This section need Trot be completed if the permit is for ora hundred dollars `r "' I''.P i.'•''
(SI00)nrles")
I ceni rwhi ... ..'. .. _ .- _ . . .. . _. - -
fl that in the p in any ma of the work for which this permit a orkcr I
'hill mrpini employ any person in any manner w as to become subject ro the Workcm; "
Compensation Lewes of Califomie.Dem
NOTICE TO APPLICANT:If.after making this -- - should _ ..__. .. .. .. ......._._ .— .. ._.._.. ._. ......_..._. _ _ _ _ .....
Genian, e h Exemption.You should
Obecomesubjectcomp y the Worker's Compcmathis p.it sds of he Labor Code,you mon
fdnhwiN comply with such pmvisinns or this permit shell be deemed revoked.
FZr' .~�. " -" CONSTRUCDONLENDINGAGENCY -
�a ' 1
hereby affirm that dere is a construction lending agency ror Ne performance
Ls7 ofthe work for which this permit is isaued(Sec,3097.Cis,
CJ
Q 1sndKs Name '
Z Lender's'Address
U O 1 ramify that 1 have recall this apphemion and sone that the above information is .
W F., im eel.1 agree m comply with all city and county ordinances and state laws relating
U to building commieur :ard thereby mumorixe reporamurnses of this city to enter upon
W the ahovcmentinned property for inspection purpses_ .
rF. C6i (We)agreem save,indemnify denify and keep hamdeea the Cil,of Cupertino against
yliabilities,judgments,costs and npenses which may in any way scenic against did
U ,Z City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: r Date
SOURCE REGULATIONS. y'
Signature of ApplicanUContncmr " ' ";Date Re-roofs �� 1 't_ �5 `
HAZARDOUS MATERIALS DISCLOSURE ( l
wiilti,eappceanoorfuturebuildingweapantsmrewnanmehatmWsha;tend Type of Roof
as definN by Ne Cupertino Municipal Code.Chapter 9.13.andthe HealNand Safety .,,•,' t `,t
Cade:Seniors 2553NaN. .. > r. 5, s ., 1f.• ai
c...,
°vas y.'' ❑Np,: ; ;-r "i' All roofs shall.be inspected.prio[to,anyroofing,material being installed..... _.... ... ..
W'll th .PPI c
not future h dd'ng occupant use equipment de es which If a roof is installed Without first obtaining an inspection,'I-agree to remove
em t M1 xameus a tenor mmams as dcfned by the Bay Area Air Quality Management
'
Dntrien all new materials for,inspection. Applicant understands and will comply with -
° °"n all non-point source regulations.;
t ""Y'sa Tead the hazardous ting'Is requircurvirlsu and,,Chapter'6.95''of the
Califomia Health k Safety Cade,Sections 25505.8533 and 25534.1 understand that
if the budding does not currently M1ne a mail,that it is my responsibility to notify the
occupantcof the requirements which must be mcrprior to ivmm'
aeb_f a Certificate of
"' `` pm'cr_ --' _ Signature of Applicant Date
Owner pr sermon:ea agent Data All roof coverings to be Class"B"or better
-•
'i .., ,.. .... .. .: _ OFFICE .. . .. .. . .
t