00100081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HOLDING ADDRFsy:109 OAKLEAF PL - GOSAL HEATING&AIR NDI"1"IONING001.00061,
OWN17R'S NAME::1 IO ION SI i
JEW THOMAS S AND ALIPRAID JOAN 2679 CHERRY BI_OSSO I'GJA 1. 1./2000
HONE: (510) 441—^310 SANTT rARY No, CONI ROL NO.
C eco O ARCHITEMENGINEER: BUILDING I'ERS11T INFO
p HLDG ELECT YIASlf Mlicll
y.up J _
QL
Z SN2[ LICENSED CONTRACTOR'S DECLARATION DBSCrlptloll
�C It, hy;l lrot tbw I atn licenced tinder pmvisions of Chapter 9lcmninencing
<`4C, wimzcea��;noae e'rr ra�.ln�annne ln;ame..nnd rrnre..innycnde.;tml;nr li<en.n FURNACE
z rc z i I.icn •Class a_l..i�0_ Lic.K— U__� / t �"
jf O a N Contractor
ARCHiI'ECr'S DECLARs'ION
C 1= ¢ I understand to, In;t� us 61 t
ce i3 F .0/r //c ///GIN✓ 1
u i O Licensed I'nrks\ianal
LL t NERNER-aULARATION Q/
1,teeny nSedrat 1m esuntpt from the Contractor's License Law for line
mO
follow
ing oron.(Section 911 S,Ikdinc,x and 'rarresino,Cudc:Any cloy nr mumy ,
S w'bich requires a permit to canomet,alter,impan'e,demolish or repair any swewre
W W` prior) t 1. requiresthef r dh permit rile .tutcmcnt
a. m,th 1 dp tt m p , nn c t t L 1 snapwr9 Sq. Ft. Floor Area Ynluat - 75
,onnnna , a],See n 17000) l S,cion x or the Ih,,mo's i ulirt .. ,Coda) ��/
or ohm he ix ascmpr threat, I and the ba.i,for the alleged exemption.Any violatlan
of Section 7031.5 by any applicant fora permit whjcetc the applicant m a civil penalty
of not tome man live hundred dollars($500). All �Wd_OhO45. 00 Occupancy Type
❑1,us ownu It the pt'opcny,ormy e.... ,r,with wagowa,loci-olemtnitnsatlan,
will do he work,and d e structure is not imenaled no offered for odd(See 9140, RC
''
Raciness and Pmfe,sion\Care:The Contractor',Litems Law does not opply m an
owner of property Who nuad,orimproves thereon.and whodoes wchwork himwif 301 — ROUtW'$L�i+�rV�i
or through his own employees.provided that such intprwenem,are out amended or
..Relied nxOc.lLnnwcerr, hemtild'n" aimpmoctnetnis.nldwithin line yen'It 303 — ROUGH MECHANICAL_
completion.the owncrhuilder will hory the burdenof proving drat he did oat build or 304 — ROUGH ELECTRICAL
mpmve for propose of w1f.).
0Las awn,,al hepmlany. acla-velycontracting will%licensed contractor,to 505 — FINAL_ ELECTRICAL_
Lrn,tmet the p,(,,,,,(See low.11 Ill and llo,las,ior,C..h:I Tne C... racle,, _ - 507 — FINAL PLUMBING
iven\e Law does ant apply man owner of property who build,ar impmve,there....,
and who contracts for.such projects milli a conmaI licemed pursuant to the 508 — FINAL MECHAN I CAL
contractor,License Law'.
❑I am exwnpt under See. .II&Y C for this reuxon
Owner 1)to
WORKER'S COMPENSATION DECLARATION
I hereby attired tondo penalty of perjury one of the follmv ing declarations:
T37Mave and will n tudarin a Cerin ice,of Consent to\elf-insam lin Worker's
04, matfon, as provided for by Section 3]tlll of the Lobar Cade, for the
munce of the work for which flu,permit i,mired.
ve and will tnoinumn Worker%Compensation Insurance,ns squired by Section
f the Llror Code•fur the perfommme of the work for which this permit ix Sly�Weo�rk-e,r�s CTompen,toom(Insurance cmricc,and Policy number arc:
anot, CNo
�lJJ_11e.LrQ_%I!MPoiPIION FR( WtO KERS "
COMPENSATION INSURANCE
(no,vection reel not he completed d the prroul is far enc hundred dollars
(S lqp nr led.)
I candy that in the performance of the work lar which this permit i,i.dued.1
shall not employ any boon in any mmner so t 1, nyt%jgc'1 m the Workers
Compensation Laws of G%lifnmiu,Dine �Q/ �V
Applicant
NOTICE TO APPI.IY,i. . I na tog this Ccru¢mc of Esnnption,You mould
become,abject to the Workers Compensation provisions of the labor Code,you mot
Q O hmhwith comply with such pmvisions or thi\permit shall he deemed revoked.
CONS IRUCTIONLELADING AGENCY '
7 1 hereby affiml thin there o a cnn\wction lending agency far the perfmnnanae
of the work for which this permit i,issued(Sec.31'N].Civ.C.)
P. E Lender's Name
D L Lender's Aid.... .
U 0 I certify that l bee rcal,ld,aladiemunand,woe unit tire ohne information is
R E.orrect.1 agree to comply with all city and county ordinances and swm laws relating
O
ca
building I, twonfion,and herchyautharire re,no,couoa,armis city ro enter arm
rJ] tha ahove,ncntioned Prupcoy tot inspection pn.paws.
Ems, li (We)altorn,,av,indemnity and keep harmlem the City of Cupcaino mea 1
Vi liabilities,judgment\,costs and cI lwoaa which may in any way accrue against said
U L Cuymer an I,of the gramingof this permit.
AYPLI N'1" •RSTANDS AN)YLL COMPLY WITH ALL NON-POINT Issued Date
SOU 'If RAl'I( S y'
S' ammor_/%rp[I l 'amra ,r m / / )are Re-roof
L'(JJ// :
HAZARDOUS MATERIALS DISCLOSURE
wdl the applicant or future nmldmg occupant one(it na.ardm%s material Type Roof
vs dd lusl by tae Cnprolno Munkisel Code,Chad-9.12.and the Health and Sat'oy
Code.Section 255321o1:' ON.
All roofs shall be inspected prior to any roofing material being installed.
Wldthe appddmnoretutmneIdingoncapand to'dy'lipmcatorda,wrxwnielt If a roof is installed without first obtaining an inspection, 1 agree to remove
emit horvnlnus oar umunniontx o.Acfnal by the aayA vt Aar Quuliry Mnnngrtnem
DiatHctO Yes ❑Na all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I bane red the haorlous materials tuoryimmenn node,Chapmr 6,95 of the
California li th&Smaly Cod,.Sections25505,25533 and 255311 andcrsmnd t but
it the build' ce\not curremly hast am an'.that it is my rasponsihility rat irdif,dw
occupy f c forenenu which mu tie nr-t prior to issuance of a Ceoificac of
°aa' ' Signature of Applicant Date
a �[�
roe fid agent All roof coverings to be Class"B"or better
or
OFFICE