01110050 OF
CI UILDIING DIIVISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
937 NOVEMBER DR FALCONE AND SNYDER CO IN 01110050
DC �N"A'AARIE A 650 LINCOLN AVE APPLICATION11/08/2001
PHONE: (408) 292-9705 SANITARY NO. CONTROL NO.
E 1.O ZO ARCHITECTIENGINEER: BUILDING PERMIT INFO
pr❑ BLUG ELECT PLUMB MF.CH
Cad
y i LICENSED CONTRACTOR'S DECLARATION Job Description
Z_o Ihereby affirm ivi1nmlicensed filmBunder provisions ofChaper,Coale (commencing REPLACE FURNACE .
,_mFuJ with fan ion Al ad
Division3of the Business and Professions CaJe,'nd my license
is lull force and a
m a 6 Licenx Class 6Lic.N
1 a N Date Contractor n
CHITECT'S DECLAI ATION I
ar unden�my plans shall be used as public records
i
1�p O Licensed Professional
'd OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Conmaor's Lioeve Law for the
following mason,(Section 7031.5.Business and Professions Code:Any city or county $2500
which mp.ma,.parmitt c i t Iter,improve,demo)ah orrepayany nmaum
ad
3 m -poo t t Lao xy res the pplkam for such Parton to fleangtwl suumem.
1 mat hi isInitiated:p rsmW tC lye fainvisams.of the Cixmctors Licenx Law(Chapter 91 Valuation
(co a
nngwith Sato 7M)of Division Sof the Bushes,and Ptpfessons Code)' �•(,iR I i3 p'�9]_`11741',r;V�ja aq,k wi•t.i�.1:
or that hels cacmot therefrom and the basis for the allbgad exemplI Any violation
l of Section 7031.5 by any applicant for a parman subjects Ne applicant to a civil penalty'
of not mom man five hundred dollars(S500). 301APNhl'3BtSH PLUMBIN1 • • Occupancy Type
❑I;m owner of the property,or my employees with wages as their sole compensation, — ROUGH MFC &L
will do the work,saidmeswcmre is not intended or offered for sale(Sec.7016,. 3 0 4 - ROUGH EI3�fjlHR(l EAlactions"'
Business and Professions Cade:The Conuacmr's License Law does not apply m an "t
owner of property Who wilds or improves thereon,and who does such work himxlf 505 — FINAL ELECTRICAL
othrough his own employees.provided that such improvements are not intended or
offered for sale.If.however,the euildmg or improvamard is sold within ora Year or 507 - FINAL PLUMBING •-. _ .. .. _ _
opowefoor ma overt ofsie.).will have me wmen orpmving toot he did not moxa ar 508 - FINAL MECHANICAL
, impmvc purpose -
p 1,as owner ofahe prupertY i ively contracting wish i censed contractors to . .. {_ ... _ t .. ...
construct the pmlect(Sec 7030 Business a"Professions Code)The Contractor's � ,• s
License Law does not apply to of property who builds or improves daemon,
_ and who contracts for such projectv with a contractors)licensed pursmm to the . . _ .. ._ . _ _ _ _..
Cormmenols License law.
❑lam exempt under Sed'_'t- .l ;BAPC for this nasoC��� C
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pgnatty of perjury one of the following declarations:
❑ I have and will maintain C n fiat o of Consent t farWorker
Compensation. Provided ( by Section 37on 7]00 f theLather
bra Code for the
' perf. bf th oil fo h h th.permn r. d
1 M1 d II m Wok C pc i 1 sit once a red by er i /
100 of the labor Code for the performance the work f which thisPermit i
i iss k 1 n d My``W Compens ti [ J Policy bra
Career` rT 'a�P f yN ..-,; •`k-�•;,r,':' ; '� :":• l i•-,. TT _ . . O/:1 '. r
"'`i CERTIFICATION OF,EXEMPf1ON OM WO RD v i
y r,l ,.u'. •J1tl s. .J oe._.r. Sl.y.t: 1
....,. p.. �..�COMPENSATION INSURANCE''.
(This union need not be<ompinW if the permit is five one hundred dollars t
IS 100)or less)
1 ceriifY that in the performance of ilia work for which this permit is lasuad,l
shall not employ any person in any manner so to'no become subject to me Workers't
Compensation Lows of C011fornla.Date
r .Appl t _ :_ ..... .. . .. . _
NOTICETOAPPLICANT 1r f meka g th C n Ocdm of Eaempnon you should'. "
boom b) t t dae Wo ke s C mpens t p 's ns of me labor Cade you must
O 0 forthwith comply with such previsions a this Permit shall be domed revoked
I
F CONSTRUCTION LENDING AGENCY
1 hereby affirm-that there is a construction lending agency for the,performance
W .moi of the work for which this Permit is ismed(Sec.3097,Civ.CJ
(� Lender's Name _. ..r... ... :... . . ..... ... ....:. _ ._ ..
'Lander's Address "' 1 •
U O I cenify that 1 have read this application and state that he above information is
cortex.I agree m co y with all city and county ordinances and state laws relating
O U •to wilding const -n of hereby authorize representatives ofthis city toemerupon
} the above-menti ed p rty for impectio List s. _
t (We)a aVsa e.indicated a cph ass the City of Cupertino against'
r VV, .liabilities,jud mens, n an a us hie ay in any way Laterite agar v said', 117
U.Z City in cons senate o t s glen g full PF tip
'APPLICA UND NDS DW LL PLY WD14ALLN -PONT Issued b Date
SOURCE EGULA N y'
Signature PfAppla"HAZARDOU, - " r ate -1 Re-roofs '�_/ _ J '` �' y- r�r
'HAZARDOUS MATERIALS DISCLOSU Vim' L.
a viikihe applicant or future wilding occupant sort or hard harandous matmall Type of Roof, - --
as der m
d by,lhe Cupcn t Municipal Code Chapter 9.12, a theHalm ,`
and Safety' , tl
Code.Secun25532( 1 t r , ;? n P1� 1.,:�':�e•.I.ti{'ls ..a :.
'ovek- '• ;orin ? ;:•:';".';':. : _ All-roofs shall be inspected priocto.any roofing material being"installed..... ._..
Will me applicant or future building oecapenl_use equipment or devices which, If a roof is installed'without first obtaining an inspection,'I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
Dixtrict7 all new materials for inspection. Applicant understands and will comply with
❑Yeq ;, No - all non-point source regulations.
I cd Lia a a' ltcnidx requirdmcndi under Chapter 6.95 of dad
rat's) v Ith at e, cations 25505.25533 and 25530.1 understand that .. _
fi but n in an cure ly e a tenant,mat it is my responsibility to notify.the
upon o th in, e s must be maYprioi to issuance of ani teat of;
°;`aPa` Signature of Applicant Date
y � _
' ter or antnodxa agent. .t Data All roof coverings to be Class "B"or better