01100036 CITY
BUILDING DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10727 PAR THREE DR CONDITIONED AIR 01100036
OWNER'S NAME: APPLICATION SUB DATE
LOUIS A. SCHMIDT 164 B GILMAN AVE 10/05/2001
PHONE: (408) 374-6311 SANITARY NO. CONTROL NO.
O O ARCHITECDENGINEER: BUILDING PERMIT INFO
m BLDG ELECT PLUMB MECH
I I
LICENSED CONTRACTOR'S DECLARATION
' i2 0 z I hemby anine mat 1 nm 0ee.sed anderpnwrsmns o p g fCha ter 9(e°mmenein Job Description
5 yn�
m7m wimfllfon7Bbl)efDivision3oftheBosinessandProfcssionsCmle.endmyllcen FURNACE CHANGEOUT
I.al isinforce and eRm. �Bt_ _���®
eco i u License Class Lic.li 1,•!tlV
Date S DECLARATION
i LL 0 ti, ARCHITECTS DECLARATION
O 1 understand my plans shall be used as public records
oo LicensedPmfi,,lonal MAY 2 9 2002
OWNER-BUILDER DECLARATION
usi= 1 hereby affirm that I am tone t from the Contncmr's License Law for me
FZQ
following reason.(Section 7031.5.Business and PrafcssirytsCoae:Any city orcounty t3UtLDt�tYl 1
FF O which requires a Pemsit to consumer,alter,improve,demolish,or repair any atructum
Ccs Iminsaitaismonce,also rcquims nc�.Dplicam fm such permino Bleenigned«atemcm -
tecarmelionwtl Sectio 7")o the ifDiionsnf the 3ofheBromhLianxlawonsCor9 y, �gfy�I/•�,{(mr boa, Valuation
(comm enc ing withSectionther,n7000)ofDi Isisisor t the Business and Professions Code) f f :�i.i13—'.`.+.,V '`Ya?Y.•eVttat.M1l. te,l,�l:•t
or that he is exempt tncrcfmm and the basis forme alleged exemption,Any violation
of Section h any applicam for o permit subjects the appliam to a civil penalty i
or actnor mare roand five hundred amlaix(ssoo). 3 O lAPN Vt'JThSH PLUMB IN Occupancy Type
❑1,as owner of the property,to an,employees with wages as mei,sole compensation, 303 - ROUGH mpr�TAN
will as die work,dna the ode:Th is not Contractor's
intended or offered for sma Is«.7o),1,1.Busines3 04 - ROUGH EIRWMRd i�Rlleetions
will do t and Professions thi Code:The is all sor o law dad nm apply m an
owner of propemy Who wilds or improves thm
ean,and who does such work himself 505 - FINAL ELECTRICAL
othtuugh his own employees.provide that such Improvements me not intended or
offered for sale.If,however,the building or improvement is sold within one year of 507 - FINAL PLUMBING
completion,the owner-wilder will have the harbor of proving that he did not wild or
improve far parpoxofa.le.). 508 - FINAL MECHANICAL
O 1,as wvor,of the pmpen,cam'.Ot ivdy contracting with licensed contractors to ,
omwn drc pmjeer(Sec.7t10i.Business nM Professions Cox:)The Commnore
. License law does not apply to an owner of property who builds or improves thereon.
and who contracts for such projects with a commucmr(s)licensed pursuant m the
Crinolines Littnx Law. I ,
0 lam cacmpt under Sec. ,B&PC for mist lesson i
Owner- Date _
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
O 1 have and will maintain a Certificate of Consent to self insum for Worker's
Compensation, as provided for by Section 3700 of the labor Code, for me
performance of the woA for which this perman is issued.
❑1 have and will maintain Workers Compensation Insurance,as squired by Section
- 3700 of the Labor Cade;fm the per rommmtt of me work for which this permit is
ycompensationlnsumnee courier and Policy number art:
issued.M Worker's .. .... ........ .. ... .. :. ,,. ... .._. .._.. . _... ...
Ca,iier i: i Policy No.: r ! v 'r t'`v;•i l
CERTIFICATION OF EXEMPTION FROM WORKERS' o •� '
i COMPENSATION INSURANCE " _ -
V' a It.
(This rection nee not be completed if the permit is for one hundred dollars .
($100)or less.)
I certify chat in the fre fonnonce of the work for which this permit is i...ed.1
ihml not employ any person in any manner so air to become subject to the Workers'
Compensation laws of Calitoraria Dae
APPlicaul - - -NOTICE To APPLICANT:If,after making this Cmificare of Exemption,you should
Q O become subject to the w'orker's Compensation provisions of me Labor Code,you must '
forthwith comply with such provisions or this permit shall x domed xvaked.
in CONSTRUCTION LENDING AGENCY
1 Inanity affirm that mete is.construction lending agency for the pou(omance
Wof me work for which this permit is issued(Sec.3097.Cr,Q
Y Q lenders Name
Q Z Leader's Address .
V 0 1 comity that I have reed this application and stme that the above information is
I,.'t: correct.1 agree to comply with all city and county ordinances end state laws relating
�.V to wilding construction,and hereby marmize representatives ofthi.s city to emerupo°
the
(r•^. Lm ewtioned property ipupaa
(Wej,age tsu'aindemnfyand!keep,Journalists
Cupertino avib/�
liabilities,juddgmcer indemnify
which yin any way account guinstd
C.) z City in ANT UNDERSTANDS
of the NDS graming D this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTIuedb r Dale
Issued SOURCE REGULATIONS. � � Y�
signature of Apprcan✓Camraemr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
.. Val the apps ann or furore wilding occupant arm of handle hain,dws material Type of Roof .._. . .. .
as defined by me Cupertino Municipal Code.Chapter 9.12.and the Health and Safety Is
Code,Section 2{5321,1)?
ores CI No All roofs shall be inspected prior to any roofing material being installed. .. .
Will the applicam err forme building occupant use eyoiprorm or devkes whim If a roof is installed without first obtaining an inspection,I•agree'to remove
emit haaardoua it,emmininana as defined by the Bay Area Air Quality Management
Dimmer? all new materials for inspection. Applicant understands and will comply with
b❑ 0Yes °N° all non-point source regulations.
V I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safny Cade,Sec moss 25505,25533 and 2553,1.1 understandthat
ifthe wilding dos anresi endy have tenant,that it is myresponsibility to notify the
oi,c.,n t of be requirements which must he met prior to issuance of a Certificate of
Cocaputracy. Signature of Applicant Date
owner or aarnoriaea agent nine All roof coverings to be Class "B"or better
' ! OFFICE