01060169 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20239 NW SQ SCHAUMANN PLUMBING AND H ATING01060169
OWNER'S NAME: APPLICATION SUB DATE
KHANNA AJAY 1455 LAURELWOOD RD 06/28/2001
PHONE: SANITARY NO. CONTROL NO.
(408) 986-9044
M bcz ARCHITECT/ENGINEER: BUILDING PERMIT INFO
- BLDG ELECT PLUMB MECH
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LICENSED COMRACTOR'S DECLARATION
z 5„_ Job Description
O z- 1 hereby affirm that 1 n 3 Bcerned under provision.of Chapter 9 kommecerom -
P_�w wire Scctfre dnfcl,ln,t3anbe Ba.itte..Pena Prore>.h,n.ease.Pena myfian.e REPLACE FURNACE/ ADD 3 TON A/C.
M. , i.infullfow; pJ of ca
M.a Licrnu C ass `-C•'�O •' Lic.p 2�2/-]&
ale Commc orSDYAeLmnw/n
r.u
O'r' ARCHITECT'S DECLARATION
1 undcorand my plans.shall be used a,publ lc means
be
i c❑0 Licensed Professional
OWNER-BUILDER DECLARATION
Or I hereby ulfirm that 1 am exempt from the Commaor's License Low for the
Iz mtk win,ressim.(section 703 IS.Basin...and Profession.Coe:Any city or et.rnry $6269
zO which mquims a permit to constant,alter,improve,demolish,or repair any s menrc
ty-c to .. . II 'III' '
a5 (co hmenc ,with s«t II'oJtire
")ur of ionolemons t3tire
of,k Emine LIM Pmicense esx onl.Codes ( 31 ejV l�orz+k�sw `• ; Valuation
.,,bar he is exempt theteftnnt and he basis far the ollcgcif en imp imi.Any violation v v
of Section 7031.5 by any applicant into wont subjects the applicant to a civil penalty
of not mom than fiKhundred dollars($500). 303APNRbT&,N MECHANI Air "' ' Occupancy Type
111.as owner or the pmperty.or my employees with wages as their sole compensation.
will nc me wnrk,and me ode Tei..m(intended or eLw lire.ale(Sec. 1.an 5 0 5 - FINAL EL Fiel1(bAPs
Bminm.and Professions Code:The is License dor Offered Law dor nal( 1 to 4. CI]OHs'
ow of property Who builds or improves thereon,and who does such work himself
pr though his own employees.provided that such improvements art not intended or 508 - FINAL MECHANI CAL
offered fsale.- If,h theb ldin t t s sold within ore f - -
g or that
proof pro year o
completion,the ' II h the burden of proving that he did not build or t
imp rose for pugac of
I ).
El I."Sx er of thee Seen am..aexclusively contracting with licensed!cvocmmm
consumer Ih forjectIS 70o14.Businesv and Professions Carl Th CommunaCs
License Law d m apply t an of p pnwho Wild, reprove, he..
nd who contractsfor such pr¢ with a contmmmlel 1 cereed.purs vt to the
Cartoon, L cam Law
11
❑lomexemp(under Sec. .B&,PCfar this tearon
Owner Dme
WORKER'S COMPENSATION DECLARATION
-• I hereby vRrm under Penalty of Perjury one Of the following declarations:
❑ 1 have and will mamLide Certificate of Consent to self-inwre for Worker'.
Compensmioq m provided for by Secllon 39W of the Labor Cade, for the
pantmor nce critic wnrk for which this permit is issued..,, ,
❑I No.anti will mama in Worker's CSmfpsm,r on bosun a, required by Section
39W of the Labor Code,for the Performance of the'work for which this permit i.
issued.My Workers Connf,coation Insurance carrier and Policy number am:
Carrier:O�TATf' •'_Policy NO,: -cd9/ dOlLt'SQ .e ... .-_._ .___._._.. m .. ..._.... .. ._._..
CERTIFICATION OF EXEMPTION FROM WORKh `•
COMPENSATION INSURANCE'_ '
------
This section Iced not be emnpleted it the permit Is for one hundred dollars .' t I.1•.
IS IW)m les.)
terrify that in the,Performance of the sboh for which this permit is ioambL'1 -
'hall not enploy any person in any,nnnoer xo its to become subject no the Workers '
Compensation Law.of C'ililomie.pat
Applicant
NOTICE TO APPLICANT.If.of¢nnaking this Ccnitiene of Esimption.you should '
Z O becomeh hccf It,IhWuchxre Cum anon ioi,ofmc Labor Code.you mus,
p y OilprovisionsorPenn
' shall M AccmN revoked.
p•^ CONSTRUCTION LENDING AGENCY
a1 herehy affirm thin(here is u constmc inn landing ageney fur the perfarntance
>
W.> of the work for which this permit i.issued(Sec.3097,Cls.C.)
O..5 Lender's Name.._- . . .:....:. .. ..
zLemic ABdm%,
U �I certify that l hove read this appliceion and.state that the above inform coon is
c.,.1 agree m comply with all city and county ordinances and stare laws mining
f..)
to building etoomartmin.andhereby authorize representativesof this 'ty to enter upon
the M1 d prolverty for ropectionp p
t�. d IW 1 6 I 'd 'ly nJk ph mccy fCupenimallord
Vi li b I t j dg t. cat M expense hmch may m any y c against sat d
(.) Z
City I. f the flooding of thismon.
APPLICANT UNDERSTANDS ANU WILL COMPLY WITH ALL NON POINT
SOURCE R:000aTI)Ng. . Issued by: ell^_— — Date �O
. 51gnamre of Amlicantfcontractur +,.,Data. Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant a, buildingceeuPam'snie or handle Imundoa,material 'IType of Roof .•.. _.. '- _. .. ... .
as defined by the CupcnimpMunicipal Code.Chapter 9.12.and the Health and Safety
Cote,Section 25532a)7e -
❑Y<e
' n ti 1 _ • , alied.. _
All roofssfiall be mspected.pnor toany_roofing matersal being inst.
Will the applicant or future Wilding occupant use equipment ordeviees which If a roof is installed without first obtaining an inspection; I'dgree to remove
coni,haiaodnu.air cnnwmina defined by the Bay Area All Quality Management
District' . � all new materials for inspection. Applicant understands and will comply with
❑Ye., Na I Iall non-point source regulations.
1'have read the hazardous materials requirements under Chapin 6.95 of the
Ca lioria Hea m&Safety Code,Sections 25505.255A and 25534.1 understand that
if theWilding duo not currently have a tenni;that it i%my responsibility to notify the
occupant of me mr aimments which,oust be ren no,m is.aancit of a Certificate of
cu
Ocpancy .
GO� Signature of Applicant Date
,��
Ownermgamadeeda,ent - Date All roof coverings to be Class "B" or better
... .. :_, .. . . .. .. .. , .... .. OFFICE ._.