02070059 CI BUILDING DIIVCrISSIIONNO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMTf N0,
1081 NOVEMBER DR CONTROLLED SYSTEMS OF CALI . 02070059
OWNER'S NAME: APPLICATION SUB DATE
RAN SRINIVAS 2283 MORA DR 07/10/2002
PHONE: SANITARY NO. CONTROL NO.
(415) 964-8354
sn-rARCHITECUENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I-1 1__I
5¢N= LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
F_tm wih Section 7000)of Division 3 of Business and Professions Code.and my license REPLACE FURNACE & ADD A/C
��y; is in full! e .d Ru
6 License Cis an_p �O Lic.N I J Z
°'O i U Da¢ /s C� Cnmmcmr
ts�j LL ri• ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
W9 O Liccnud Professional
as OWNER-BUILDER DECLARATION
1 hereby from that 1 am exempt from he Contractor's License Law for he
f- a following moon.(Section 703L5.Business and Professions Code:Any city or county $6400
E F C which requires a permit m construct,alter,improve,demolish,or repair any swchim.
pof rior b its Issuance atm requires heapplicant fur such permitm file a xi,salsutemem
of3 -
do[he is�lianad purwara w do,provisions of the Cmamm ors License Law(Chaptar,9 Valuation
0 36fiWO' T e aro,.;,
or he is cempt therefrommaand the basis for the a0 ged e4dmptnnrAny professions
anon \-';.)i4"�'.. u' ec3:r:a'F l?:� '
of Section 7031.5 by any applicant for a permit subjects he applicart to a civil Penalty
sof not,more than rive hundred dnnams(s5(ao 301 AlyN kTM ft PLUMB IN . . Occupancy Type
°I,as owner"f he property,or my employees with wages as their sole compensation, ROUGH MECHAN LT',
'-will do he work.and the stmcture is not intended or offered for sale(See.761;1 -' - -
Business and'I'mFessions Codd The Contractor's License Law does not apply to an 304 - ROUGH ELWWRd Q etions Ito`l
owner
r mraofn his ow amowdttssormmetee that sun imdwho d;ssamcnot ins sea er 505 — FINAL ELECTRICAL
g P r pmci '- - --improvements
completion,
isle:If.htiwuildehe wili Wilding n<ntdsold he did one rear of _. . _. ... _ _ _ _. .. "PLUMBING
.. _ __. __
completion,h<owner-builticr will have the burden of proving that he did not buil)aro 507 - FINAL PLUMBING I '• '
improve mrpurp,seofsmc.) 508 - FINAL MECHANICAL
°I, .omner of fire pro n- tat evduwith
.... _. _. .. .. _.. .. .. ... . _.. . ........ .. _. _._.. _ .....--
ec Y dad ori ng w h T he Conca,ra m + I I+-
_
construct the pretest(5cd 7(a a Business pro cdy who
b Cudeq The Ca thereon, � 1 Li' I
I: f. m u m
License law does not apply ban owner of property who builds or improves thereon,
i and who ns for.meh prolttu.with n.commctorts)licenud pursuant in the.
Contractors License
❑Imo exempt
mpt under Sec. BffiPC!..obis reawn 1• ..
—_ .. '• Owner NS
WORKER'S COMPENSATION DECLARATION flfl�\V{I
1 hereby affirm under realty of perjury one of the following declarations: JULs• ° I have End will maintain a Cenifcam of Consent u, self-insure for Worker's U 1 2 2002
compenati
son ash
.provided for by Section 37W of the Lar Code, for .he
performance of the work for which this peranit e,issued.
r
vs,and will maintain Workers Compcnsaion Insurance,as sectored by Section BUILDING
B I'1 ����
l7W of the Labor Code,for the performance of the work for which this perBU
mit is
issued.My Worker's Compensation Insurance cart er and Polcy number am
Car 'y No,
/OISf9-GS-7g r,v _. _. ..
I • CERTIFICAII N EXEMPTION I'trON'WORKERSa 4.. . .'rl.. ht % !" ` J9 t. l.. '.J ."
COMPENSATION INSURANCE"
'(This se&mn need not tie completed if the permit is for one hundred dollars f.
t
(Sim)aro less.)
I certify yhai in the Performance Wine work for whim this permit a issued:I
shall not anon 'set tperwo Culd o any manner m as m become whjcn m the Workers'
Compensation Laws of Califnmia.Date
..APPhcant _ ._. .. .. -._ .._... .... ... .. _.. ...... .. ...
NOTICE TOAPPLIe Worker'If.s
Co mnsatilan,this
ov Niacme of Exemption you niuld t
s,
berthwi hcosubject y the Worker,Cd.....r iof provisions of the latwr Code,you must
z Q fn. - comply with such prnvitions aphis permit shall- deemed revoked.
DO CONSTRUCTION LENDING AGENCY "
1 hereby affirm that hem is a construction lending agency for the partiorentt r '
GS7 of the worfor which this permit is issued(See.3097,Civ.C.)
a' Lend Addrc
1 ceftify that I have mad this pplict and-,late that the above information is
Its [y
correct.I ri,rcr to m nply ,,in all u 1)and coural,n'dinances a td urns laws relaeg
[) ...building contraction.and hereby authorize representatives ofthl.s city to enter upon
ms
�„ ryt the above-mentioned property for inspection purposes.
[.. S (We)agree to save;indemnify and keep homeless the City of Cupertino against
V] liabilities,judgment.costs and expenses which may in any uay seers against said
City in comequrnce of the Brami r,of this permit.'
APPLICANT UNDERSTANDS AND"'ILL COMPLY%x* ALL NG.'PG1•Y Issued b ` Date
rr v v
SOURCE REGj1.ATIONS - 7,/O em y'
Signature of A,llcunt/Caroact r '^ four Re-roofs '
IIAY\RD MATERIA(S OISCLOSURC
❑xurY un the
eh�nphp<amt urfirr holding«. ptstore or handle lt mt 1.
_Type of Roo"f...
nsd l dbdoCar o M cid Ch pt 9 12.and theHealth J Safety
Cad Y .i
> ho
iAll roofsshallbemspeqcte.sd.,pnor t_o..'_a(ny roo..f_in.g-..material being installed.
tom
lure
Wilding .
.- - _...
occupant use equipment or devices If a roof is installed without first obtaining an inspection,-I agree to remove
mit bromot us air cnmaminan s as do Sit I by tIt Bay A.A,Air Quality Management
District?. � all new materials for inspection. Applicant understands and will comply with -
°ye, °N all non-poifit souice regulations.. .,
1 have rood the hazardous materials requimaientt under Chapter 6.95 of he
Califc;am Health&Safe,y Cuda Section,25505.25533 and 25534.1 understand that
ifshe Wilding docs not currently have a from.that it is my responsibility to notify the -
tooriv m of the requirements which must be,mat prior to issuance of a Certificate of
Occupancy.
\ / -7�D/L Signature of Applicant _ _ Daze
�'• n<roramhori:<da • t' Date All roof coverings to be Class"B"or better
OFFICE .