00020051 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT (CONTRACTOR INFORMATION:
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BU;VRESS: T VAIEZ HEATER&) INC.
(] /n�/' �/ P SANITARY NO. APPLICATION SUBMITTAL DATI
O N'R'SNAMF., I / Na/c`c17""` Ave NIC CONTROL#
0If ", Ha ywanv, C�j'App 9�y6-1722 ❑
ARCHITEC rENGINEER r I (510) 293-2O 1 Z BULDING PERMIT INFO
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F l6^ LICENSED CONTRACTOR'S DECLARATION Job Description
ZZ=p I hereby affirm Nat I am licensed under,Pr vnir ,of Chapter 9(comenencing p
PyFw wiNS 1batc ,am.ivision3of NeBuinusand Rofasiom C9de,and mylicenu is
QYfJ iMnfullycema
m <
0 enJawa 1 # l�l/atPr Nester Repla�emPnt '40 Cq/lG� �i 5
O6Deu ISDECr D
g me mall be me DECLARATION
$ y I andermand my q.m shell W used ss public records
H
K Pro c Licensed Professional
OWNER-BUILDER DECLARATION
3 Y I hereby affirm chat 1 am eaempr from she Contractors Licenu Law,for the
S,x p following reason.(Section 703 IS.Bmimss and Profession.Code:Any city or county
wC which requims a Permit m commoner.alcor,improve,demolish,or rtpatr any strucmrc S FL Floor Area Valuation
e'3� microns i.nmence.ala ho,tims lW applicant f...ch perraino file it damen,signsu �' - /a
that W is inemsed pursuant to the provisions of the Co...&.License Law,(Chapter 9 / 0(d
(commencing with Sam.. ")or Division 3 of the Business and Profewaiou Core). ppN Number Occupancy
wt he is eaempr therefrom we t basis for Ne afleged essmplion.Aar violation of / _ P' Y Type
Section 1031.5 by any applfcm,for.pemul subjects tie applicant to a aril Penalty of
a more Nen five hundred dollen(5500).
T,aaawnerorthemromeny,ormremPloyen.wiNw.gaaNeiraaecompeM.tit, Required Inspections
will do the work,andthe struccon is not Imendedoroffcrad for sale(Sec.1044,Business ,
and Pofndons Cade:The Cmuumlm's Licenu law does nor apply to an owner a
propcny,who builds or improves tbemun,and who does such work himeelf or through
his own employees,Provided that such improvements are not intended or offered for ,
ulc.If,hove sr.Nc building or improvement is sold within ane year of completion,doe
cwrr-Wilda will ham de Wrden of moving the,he did not Wild a impmve for ppu-
pom of rest'). 4
I,u ower of rt Sm.l l y,un s�lusively conuuung Cock:)
licensed cmnuanon t. !//
cmc a dProject(Sm. Businessand P who Wi Coded TW Commerce's nd
nue law dines ton such
to ts owner ie property who Wilds a imaa.a thereon,and
whon.Lads for such projtta with a cantracra(a)licensed pursuant m the Condecror s
License law. O
C]I am exempr undo Sm. .B k P C for this won O
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby tufirn under pmomy of pe jury one of Ne follow,dechar mom,
U I have soul will mmicam aCenifcare afComent to uhf-insure for WarkersCompen-
ution,as provided for by Secuon 37M of the LaWr Code,for the performance of IW
V,
for which this French is issued.
V,have and will maintain Worker's Compemsarion Insurmce,as mr ined by Section
3100of rhe Labor Code,for the performance of the work for which this permit is isseuyed.
My Workjs�/{I C; IE I tp i nc5 crosier and Policy Wq�tber k¢:nn 1 n 1 TJ
Comm:-� I]f)IV Policy No,:U ICK
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section madam,W complered Jthe permit is for.hunAcd"Ire(5100)
or leu.)
I certify Net in the performance of the work for which this permit is iaue4l shall
nm employ my person in my manner so as to become subject m tW WorkerCooper'
salion laws of California.Data
Applicant
NOTICE TO APPLICAM':If,after making this Cenificate of Exemption,you should
become subject to On,Worker'a Compeuauon provisions of the Laou Code,you must
forthwith comply with such Provisions or this permit shall W dosed mvokW.
CONSTRUCTION LENDING AGENCY
O I hereby often son Inca is a construction leading agency for the pcfommuee of
Z. the work for which this permit is issued(Sm.3091.Civ.C.)
E:, www Lenders Name
�i } Leader's Addasa
1.17 1 certify that 1 have read this epPlicerion and arm,
e that the move informed-is
A. 0c nen.l agree to comply with all city mill county ordinances and sure laws elating to
.•7 Z building consvuction,and hereby authorize uprc®natives ofthi,city to emurupon the
V O above-Inemimied Property for inspection Purprom,
lis I^" (We)agree to wave.indemnify and keep humlc.the City of Cane ino.gaimt
O U Iiabiliria,Ptlgmcnts,cents end ea,.,which may in any way aceme.geiot said City ,
} f4: inconsequeuceofthegrmungof thu,ytis
t" APPLICANTUNDERSTANDSAND LLLCOMPLYWI'rHALLNON-POINT
V z SOURCEREGUTATIONS.
P— 100
S,mmurruf AmgirmuContnc r Dau
HAZARD U ATERIALS DISCLOSURE _
Wuluae,licmtorfanreBdingrccupmtmmrtarnandlebuardaaam.ar;cl Re-roofs
in defined by the.penin Municipal Code.Chapter 9.12,and the HeaIN sad Safety Type Of Roof
Cods.Section 25532or? .�/ Yp -
❑Yes lmO
Will Ne apPI ram or roam Winding mcup.nt use ac,nipmem or devices which All roofs shall be inspected prior to any roofing material being"
mitluraNmusire namirunuasdefnedbyNCBayArcaAhQualityMmagement installed. If a roof is Installed without first obtaining an inspection
Ye, MN.JM10 I avee to remove all new materials for inspection. Applicant
I have mall thehazard.,materials acquirenen
rts ander Chapter 6.95 of the C.hi- understands and will comply wit all non point source regulations.
roma Health sk Safety Code.Sections;25N5,25533 and 25534.I urtlmand that if doe
Wilding duce no currently neve.morm4 Na ii i}}my rtxpoaibilirYonaifYlW acupant
of de"do mems whieb mor W met 'eTissumce of a CenifceseMOrmi,ses,"
1 O Signature of Applicant Date
Owner or authorized,w IData
All roofc verings to be Class"B"or better
OFFICE