02010112 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19045 PENDERGAST AVE 02010112
OWNER'S NAME: APPLIC TION UB DATE
WADE JU 01f28 2002
PHONE: SANITARY NO. CONTROL NO.
µ+OO ARCHITECTIENGINEER: BUILDING PERMIT INFO
m C BLDG ELECT PLUMB MECH
d r -u 1=1 I_I cl
LICENSED CONTRACTOR'S DECLARATION
m S H i I hercb f rm that 1 am licensed under o f Chat 9(commencingJob Description
°�-� p°"""<° Chaptere REPLACE FURNACE
Fu:tm with Section Division the Business and Professions Code.and my
x , is in full force and Rtt,. _ 7l _ _ y/2
z e¢ Licensc
a.O Dam L
a.•Yn A CHITECI'S DECLARATION
=0 g I understand my plans shall be used as public rtcoNs r/-{
8 Y f�-
e.i p O Licensed Pmlessinnal
OWNER-BUILDER DECLARATION
X!2
1 hereby affirm thin I nm escmps from the Centaur 's License Law for,he
Za following reason.(Serious 7031.5,Business and Profession.,Cade:Any city or county, $2000
C'x o which requires a permit to constmet,alter.improve,demolish,or repair any mmems,
to 3 priorto its is,ticame.als.res,timex N vpplicaut forsuchpemit mfl gocdstatenam, ..
thod he Is licensedpurs->troths
, 0p "sionsofN<ContractorsLicense Law(Chapter9
le n ogpih Set 700 )of Division 3 ofthe Business d Professions Cartel ��1,..�'r l'•3'�i SL3FFfQ 9r6.6at ks , .
Valuation
_V[
or mal the is exenipl dom,from and the basis for the alllged exemption.Any violation '
of Section 7031.5 by any applicant for a pemtit subjtta the it,licam une civil penalty
ofroat am than rv<hanm<ddollar.($500) 301APN tjU lFH PLUMBIN F' " > Occupancy Type
❑Las owner oftbe progeny,ur my employees with wages as their sole compensation, 303 ROUGH MECHAN
and is not Intended-or'offered for sale(S,7WA;- ------- --'- - - '- - - - - --'- '-- ---"
-will do andPridessi ,neode:Te' 304 — ROUGH EDI�79i&TIGAdections "1k
'Business and Profasiom Code:The Comracor's License law docs not apply so an
r of property Who builds or improves thereon,and who does such work himself 505 FINAL ELECTRICAL
—
owns
or through his own employee,provided that such improvements are not intended or
_
complleionsthe:If,Nowevcc the will
havtdrirdenof tkmn sold hedid not year of 507 - FINAL PLUM N .. .r
completion,she ownc f,ade.er will have the burden of proving that he did not build or
improve tar parp°<e er.me7. 508 - FINAL MECHANICAL
thejec It .B w h rtes L-s _ ...._. .
❑1 f shep pert exclusively unci g with licensed contractors to
Li
consumer the C lap ]to a B d e Professions Cad I mp Commerce's
ht
apply r lip prey hob Id. p es0
this .Ne. _ .... .._ - . . _.
..and who contracts for ch
Contractor License
0 exempt uMer Sec B&PC for _ L)t ' •
Dwnet � are
..t . . : .. st. a 3
WORKER'S COMPENSATION DECLARATION /
1 hereby uRm,under Knaliy.of pcijurybne or rM1e fnll°win6 dedarari°m:. . �"
Lg I have and'will'isuindia a Certificate of Consent to ulGinsure for Worker's /O
Compensation, a, provided for by Section 37W of the Labor Code:for he C
performance of the work fur which,his d
ami,is issue
16' have and will maintain Worker'Compensation Iniumnco'as rcquiad by Section
37M of the Lahor Code;for'the performance of the work for which this permit is
is. J My Walker's C pe it u Insurance c roe °I y u be
y •' of cY PON r 59 -
t C RTIPICATr O EXEMPTION FROM WORKERS - s r q t T Y Y a t�� a�C-S,(,[f l,� J
I .
[OMPLNSATION INSURANCE .s -------
action
__-„,. ,.._ -... ....
.._ _ .. o.. _.._.
(Th accon need not be mmpined f do,permit is for one hundred dollars "�•• '
DI PIT) less.), r
ndy the ny tM1 performance n th o k'r fico h u pctmi ri Worked ,,l r-t.
shell not employ any peals m any manner so as to become b3ttt to chi Workers '
.. it Laws of C 11 Dare
NOTICETOAPPLICANT If. free T1sCertificate -- - - - _ ..._ _. . .... _._ ,.__ ..._ __._ . ........... ... . _ _.r.. . .. .. _. ...._ _. __........_.
'
PP
r ntah. g this of Excmpuon You should
be ubl ct so,he W k! C ion,or p v. ns of rhe Laber Cotte.you man
0 fnnh th m1y with h p ':'ons o his pwaraad:ball be Jc<-- revoked ;
'n ”r 11"CONSTRUCTION LENDING AGENCY
e 1 hcrchy hfFrm that that i.i v cn w
onion lending agency for the perfom srce
Legme
Lkfor
enders Na .. . ...... _ . .;..v .._. ✓.. ... .._ . ._ ...
r7Z Lender's Address '... i...- )s'•. 't. 'I"i ..
V' I cenily.ohm I have maJ chis apPlicmion and 9rarc tbe,,be above information is
0.�.
1- comect;l agree b comply with all city and county ordinances and%rate Taws mlaring -
.(� to building conswctien,and hereby awrim reprexnratives of this city to enmrupon
rhe above mentioned property for,ir,,,ion Purposes.;
. -y• (We).'tgree mauve,indemnifYan'd kccp harmless the City of Cupeninoas5inn
lip inbili ics.judgments,costs and expenseswtach may in any way accme agmost said
V � City in consequence of the anting of thnperadu -
APPLICAN"I'UNDERITANDS MNDIWILLCOMPLY\YITHALL/�'ON- INT' ISSUI',db Date �Y
SOURCE REGULATIONS. „ ON� y'
�/2
Signamfeof Applirimmumtmcmr .. tDmc Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
will'ilroupplicirmofutrebuld g us,cupealatoeehadl neNa nm I .-Type.ofRoof
as defined by th Cupertino Municipal Cade Chapter 9.12.and the Health and Safety 1 t
CN Section 255i2(all } 1� o^t �: 1 ht s Q{a s + rLc I
Y Quality If roofsishnstall
h inspected prior to any roofing material being mstalle_d
•
Will the ircontaminants
c t r t building or d a e hien ed-without first obtaining an mspechon I agree to remove
court he 'rc t 1. .def db theB AreaA alt hl sago s
D,riia I ' / - all new materials for inspection ApplLcant understands and will comply with
DY r (GPO ..... ,.. .
-" all non-point source'regulanons ..
.. 1h e.read.@<hazard mate"I. q mmcnts underChaptcr G.95.of the
California HeaM1E&Safety Code,Sections 25505,25533 and 25534.1 understand that
ifilm building does no,currentlybe
ram.drala is my milao sibilky notify the .._. ._ .. . . ._.. .. ..._. ._.. _ _,. ... .. ._..:.__.._ . . . ._ ......... .. .. _.
occupant arm.requirements which must he met prior to issuance of v Certifies.Of
Y< P eyy2 All roof coverings to be Class B•' or butter
2, Tly B pp ate
Applicant 41 Signature of A
o- '-- -- .
woe Date .
OFFICE . . .... .. .. ._ _... ._ .. .. ..