02120068 CITY OF CUPERTINO ��- - vv, a-
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:-,
BUILDINGADDRESS: A PERFECT CLIMATE PERMITNO.
10914 NORTHVIEW SQ 02120068
OWNER'S NAME: 10570 S DEANZA BLVD APPLICATION SUB DATE
SALUN WELLS 12/16 2002
HONE: 406 861-9545 SANITARY NO. CONTROL NO,
ARCUDE-C"VENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
�w
ZOLICENSED CONIRAM OR;S DECLARATION
I Wo ny affirm'hat l am licensed ander provisions of Chapter 9(Commencing Job Description
�pwwith Section 7fO(h of Division 3 of Ne Business and Professions Co and my license is
In sen foreeaad of 7 I NEW FURNACE
FNvnZ License fns Lic.M
_w Dau�cnntmnm . LrS ( lL
A shaDliCpd Ispu lie ION JAN 1 5 2003
yes rc< 1 understand my plans shall be used as public records
OdU
I�LLso LiccnsoJ professional
Y i OWNER-BUILDER m DECLARATION BUILDING
a 1 hereby affirm that I am exempt from the Contractor's Licence law far rite
m-00 following reason.(Section 703 1.5.Business and Profeasintu Cosle:Any city or c.Only
a'je m which requires a pemtil m construct.alter,improve.demolish.of repair any slruelure
W prior In its issuance,also re uires the applicant foreach permit to file a signed swtemem
that heislicensed pursuamtnthe provisions ofthe Contractor'sLicenscLaw(Chapter 9 Sq. Ft. Floor Area $4!Vdlt ion
(commencing with Section 7(XXh of Division 3 of the Business and Professions Code)or
i 3$
that he is exempt dtcrcfrnm and the basis for the alleged exemption Any violation of
Section 703 L5 by any applicant for a permit subjccu the applicant to a civil penalty of Occupancy Type
not mom than five hundred dollars(gS-IOL
1,as owner Of the pmperly,or my employees with wages as their sale compensation,
will do the work,and Ne structure is nor intended or offered for sale(Sec.7044.Business 381
and Pmferniom Cade:The Concavities License Use does not apply or an owner of 303 - ROUGH &AV ons
progeny who buildaor improves thereon,and who does such work himself orthrough his
own employees,provided that such improvements are not intended or offered for cale.If. 304 — ROUGH ELECTRICAL
however,life wilding or improvement is sold within one year of completion,me owner- 505 - FINAL ELECTRICAL
builder will have the burden of proving mat he did not Wild or improve for purpose of
axle.). 507 - FINAL PLUMBING
❑ 1,as owner of the properly,am exclusively contracting with licensed conductors It, 508 - FINAL MECHANICAL
construct the project(Sec.71Mq Business and Professions Code:)The Convector's Li-
cense law does not apply to an owner of properly who wilds or impri vet Merton,and
who contracts for such projects with a con'ractons)licensed pursuant o me Contractor's
License Law.
I am exempt under Sec. .B tit P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hcrchy affirm under penalty of peepay one of the following declarations:
I hats and will maintain aCcnilicare of Coment o sel6inmre for Wnrkei sCompen-
rarion,as provided for by Section 371X1 of the labor Codc.for the perfumers,of the
for which oris permit is issued.
w 1 have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Ethic,far me performance of the work for which this permit is issued.
My Worker s Compensation Imurtce'c�an,,ic,I,and policy num. ra '.�_,q<�
Carrier: '� JC'kdicy N., 11 �lJ
CERTIFICATE. , EMITION FROM WORKERS'
COMPENSATION INSURANCE.
(This less-ion need nm na atmplemd hour permit is fnronc hundred dollars(gIIXR
less)
1 trimly that in the performance of the work for which this permit is issued.I shall nm
employ any person in any manner.su as to hccomc subjecun the Worker.'Compcnwtion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cri ificute of Exemption,you should
become adopter to the Worker's Com,enwtion provisions of the labor Cwlc,you must
0Z forthwith comply with such provisions or this permit shall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
P: ZI I hcrtby affirm mat there is a construction lending agency I the prdomoce of
y 7 Or work for which this permit is issued(Sec.NoR,Co,C.)
Lk1 Q Under's Namc
1-c role, Address
V O 1 ccnify mar 1 have read this application and stare that the shove infntmation is
U. F cosec'.1 agree to comply with all city and county ordinances and sure laws relating to
O(, building construction,and hereby authorise representatives of this city to enter clam the
above mentioned property for inspection purpases.
off"' a (We)e=c In save,indem fly and keep halm fuss the City of Cupeninn agai ml
rto lianilirics.j gmcnts,costs and of Lhi swhich may in any way eccmc against said City ! V V
U z APPLIC naru TCUNDERSnf �S rAND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR C RGGULATIO 5.
Re-roofs
Signature t Applicant/ racmr ale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
JI the applicant or future building oacupaut score or handle hasardous Oriental
defin by the Cupertino Mu pal Cock,Chapter 9.12.and the Hcalth and Safety
Code.Seainn 255321x)? _J(' All roofs shall be inspected prior to any roofing material being installed.
❑Yes Irv„
Will Iw applicant or laturt building occupant use equipment or devices which If a roof is installed without fiat obtaining an inspection, I agree to remove
cmi-handouts air contaminants as JefincJ by the Ray Arca Air Quality Management all new:materials r inspection.
Diatricrl /x
❑VCs r0(N`�
(have mal the ha/ardtwsmalerialsrequimmenuundef Chapwrh.95ofdc Califof
0V.aIhon1G,,ftrt
afety Cale,Senlnns25.915,25533md25534.luWcrsund-hal if the willing fQ
ntly have tenant,mat it is my responsibility to earthy tw occupant of the
wmc bemc-pdo'misa aafaccnificale�panty. Signature ppli Date
Da All roof coverings to be Class "B" or better