01050195 CITY OF CUPERTINO
BUILDING 13IVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10791 NORTHFORDE DR A R' H HEATING 010501.95
(OWNER'S NAME: - AI'I'LIC [ON SUB Dnl'li
JEFFERSON ANN C 770 CHESTNUT ST -'05/30/2001.
LOSE: SANITARY NO. CONTROL NO.
(408)279-0722 '
O�0'/O AItCHI I'BCl'/IiNUINlililt IDG CIPLUMB
BUILDING IINpO
ILEL MECII
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LICENSED IDCONnsedam , DECLAR Cat Job Description
Cv m o 1 hereby nllirm mal I vm licensed under provizinm of Chapter 9(commencing .
F_Cw with Seninn TgX)nf Divmain.3ofthe Busincssand Pndosioal Cale.and my license
CxIs In lull force and ell t ie�YLy 2
gym, I.iecme Cl.rns_ r_ I-ic.p _(lyy�_i3 — R 8 R FURNACE-A/C ADD ON 2 0 V CUR
%O i C' halo_ �._ CTIti I DECLARA'I I�_W�•�
�3 y
C n 1 ma entarday Plans shall he use l ars public«cont
f !r
pC Licensed professional
a.LL sat I an, "emptBLUER I.DECLARATION
I hemhy athw that I am eacmpt tram he C c,iha, o License Law for the
Z a which ng rnnota(S[xrtlnn]onsint Ru Eric,, and Pmfc.e,"$ions Cale:Any airy or ununy
0 which p oar l l 'I I hf p 1 11x1 p' ny int fit re
Fluor III illalso y dicalf hill 'y dsmm mcB
that hc is ci wstpas n 0 1 nn t t lnc I Law,(Cbamoet9 Sy. FL Floor Area Valuation
(commencing with Section oro a dlthe bakun 3 arthe alleged
x and ion.Any nisvi Code)
a that he b eaemp meman[n and me bras(car auegee aemp6rh.Any violation $5700
of section 9031.5 by any applicant for a permit subjects the applicant In a coil penalty
of not...,ban five hundred dnlwr.($510). 'APN Number Occupancy Type
❑I,as oven,of me property.m my mmployeco,with wages as their vele mnpenwBnn, VIVI
will du the work,mW the str utnm Is riot intended or located or sale(See.7044,
Maxine is,and lIt"Ir"ianv'Corm:'fhu Coronation's Liam..Luse drws not apply Ir an Required Inspections
owner nrpmpc"y Who hailds or improves broach.and who stiles such work Murrill
through his own nnpinytes.pmvmed bat such imp rn.xtonal am hot trimmed or 304 — ROUGH ELECTRICAL
offered for sale It,bawcver,the building or improvement is wild within one year of
completion.the ow net builder will have the Nj of pricing that he did not build fir 501 — FINAL_ ELECTRICAL_ ENERGY
a
mrove mpm
rpo,ofsam.l. 505 — FINAL ELECTRICAL
❑1.1,,rowne,ol o proper,, el, t ti y ran d wenn he
n' III p I(S .704411 . dP f;' Cold.:)The C nu
na's
Liao: I o ,I,t r 11 nown, h ld P mum m
and who,.r Liman for sucM1 projects will a limitations)licensed p m In he ,
n Limare Law.
01 am cannpt under
Sec. .11 Y<P C for this mason
Owner Dam 6 �
WORKER'S COMPENS M[ON DECLARAI'[ON G/
I hemhy a0il'm under Panully of penjnry nuc of the fnllnwing Jeclumtio"e 11//f
J 1 have and will Inninuln a Certilitme of Consent hr wall'-insure fill Worker's N//
401 Cmrprar oh, as provided for by Section 3901 of the Labor Cale, for the
perfommnce of the walk for which This permit is i.su.III.
01 have and will maintain Worker's Compemution Insumnce,use forfeited by Seninn
37W of the Labor Cale,For the pr1ru n once of the work for which this permit is
issued.My Workers Counipennupllnn Insurance cantor and Polity number are
Carrier:_ �/v/ pulleyNor..0,91-0 er
�7
CER'I'I IlCAT10N cep E%EMPfION FROM WORKERS
COMPENSATION INSURANCE
This section need not be completed if the permit is for one hundred dollars
($1000 nn less.I -
I cenify mut in IJoe Prib.nunwc of the work her svhleh riots punnit is icwral.I
shall nth enaploy any perwr in it conrix a no en r"hoc"ora uhFO 1.the sem kcrs'
Cumpcnsadon Laws H California Mate
Applicant
NOTICE In APPLICAM1T:If,mer making this Certificate of Exemption.you should
become subject lathe Workers Cmnpnmtion provisionsof the Labs Cade.you must
0 forthwith comply with such pnrvisions or this permit shall be deemed revoked.
F ^
CONSTRUCI ION LENDING AG17NCY
I hemhy dfnn Ihal them Ix a einsulation Iendmg igeney for the perfoonerne
W G
of the work fur which his penuh is issued(Sec.Noill.Col.C.)
L Q Lender's Naas
Z I.enden's Address -
t.7 0 1 cenify that 1 hale mad this application and%late that the above Ihrmmmion is
correct.1 agree um comply with all city and county unionists and state laws mlating
V u,building convection.and hereby aromatic teprerenna[ivcs of thiccity[center upon
the curve-mentioned property for inspection pmpo>cs.
ti Ca (We)agnc mnave,mdmnnil,ral keep herndms the City of Cupcninnogeinw '
(n liabillill',lodgments,mows the expenses which nay ill any way tactile uguioel said
U Z City in endm,rvenceol the griming of lmispmmt.
APPLICANT UNDrR.SIANDS AND WILL COMPLY WI Ill ALL NON.POIN'1' Issued by: Date
r SOUI .E RIiGU1.AT101i
Sign d Appfcf� rmc„ll'c' Date Re-roofs
BAZARDOUS MA'na1ALti DISCLOSURE
Will doe apphaht rI foam baldhmg accupam shim or bindle M1taadauw muedal Type of Roof
as delimit by the Cupedmno Munidpul Code Chapter 9.12,and the Heahh and Sato, -
Code Scmlon 255321x)'
0Yu "^ All rook~ shall be inspected prior to any roofing material being installed.
Will the applicant In future building occupant use c,luipmcnt ordevices which If a roof is installed without first obtaining an inspection, 1 agree to remove
each hocaoduus our cnntionam wade fined by the Bay Area Air Unable Management
District all new materials for inspection. Applicant understands and will comply with
O Ye, vet all non-point source regulations.
I have nail the M1wummis mrednls nay ulcurcnos ander Chapter 6.95 01 Bac
Cullfomm Health c Safety Cod",Sermons 25505.25533and 255.14.1 material Ilial
it the huilling doesnot currently hove a mommaben I isrimy reapnmibllily Ir^^lily the
,ucupam of the rcyuimmmats which nmwl barrel prior to issuance or a Cenifate ill
°" "`y' Signature of Applicant Dale
ow"rrnuuthorimdugcm ���--Y All roof coverings to be Class "g., or better
OFFICE