01110115 CITY I Dwc DPERONrvo PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10171 PHAR LAP DR FALCONE AND SNYDER CO IlsC 01110115
OWNER'S NAME: APPLICATION SUB DATE
DON NASH 650 LINCOLN AVE 11/27/2001
PHONE: (408) 292-9705 SANITARY NO. CONTROL NO.
O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w— BLDG ELECT 'PLUMB MF,C
S v i LICENSED CONTRACTOR'5 DECLARATION Job Description
i¢` by affirm shat 1 am licensed mods pmvinons of Chapter 9lrommencing P
with, iionl(andofDispian3oftheBusiness and Pmfe..ions.Code.and myhcenx FRUNACE CHANGE OUT.
all for Bea.
izaaclan. C76 map
O a Lh isms 1 C-Dmon
EC
f LL a v ARCHITECTS
-DEC TA ION /
1 under,and my plain shall he used as public records
T
i a C Licenxd Professional
LL OWNER-exempt R m the CoATION
w�m 1 naso .(Hein thin I am exempt from the Casions C s e:Any c ty o for the
L:M which
requires
a(Seaton)1)31.5.Business and ova.de Professions Code:Any city or county $3200
sFowhich requires a permit m mnwmn,alga improve.demolish,or repair any swcturc
prior to its wermucc,als.exammithe applicant for such pe.t,.file a sighed
�3 w the he ls,livvaoed puquant In the provisions of the Contractor's License Law(Chapter 9 _
(commencing with Search 70(ph of Division 3 of the Business and Pmfessiaos Costs) r..6}'a.`l 1:3 Valuation
or that he is exempt therefrom and the basis for the alleged«c r iod.Any violation
ofSection 703 E5 by any applicant for a permit subjects she applicant o a civil penalty wr 7a��s�
ul not marc than five hundtr:J dollars(SSW). 30 CPN 'i�ICl7lMH PLUMBIG Occupancy Type
01,as owner of the propcny or my employees with wages as their sole compensation.
will do the work,and the stmcmre'is not intended or offered for sale(Sof TOsa.
Business and Pmfessioiu Code The Com a,ta,s License Law does ant apply n,an 304 - ROUGH ERffPITdb3aAdctions
swarf of Who hold,or int thcreaa.and wet d«a such work himxif 505 - FINAL ELECTRICAL
or propmY provided
d .such improvements are not intended or
-offac l for sale-If.however,the building-orJtm hinpmvcment is sold within one year of
g employees.Prov'
completion,the owner-budder w ill have urden of proving that W slid notbuildor 507 — FINAL PLUMBING , .
int ore for fsale.. 508 - FINAL MECHANICAL
. - t rl - ly —.._. _...__ . . ._..__ .. ._ .._.. - - -
-°1,a owner pr the Property,am exclusively cantmaing with licensed Ci contractors •. .. y ; s.
- Licscrense w rosesn (See. tot ownBm,er
anaerty who
code:)The Cantmremn,
Lid who
law does not r,applysac man owner of a contractors)
who builds or impresses themon. .
-and Connectors
License Lis such pmjau with a contmnor(s)licenssd.pursuv:t.m the
01 tmc,scr License Law.,
❑lam eacmpt unser Sec. h. , .B&P C for this.,an C'A
Owner ALEO
ENS r VI
WORKER'S COMPENSATION DECLARATION
I hereby afft notice peaelty of perjury,ase of the fallowing declarations: DEC 1. 1 2001
0 I have and will maintain a Certificate of Consent to self-insure for Worker's
K Compensation, as provided for by Section 37W of the Labor Cade. for the BUILDING
perfotce anof the work for which this permit is named.
0:have and will'mainiain Worker's Compensation Insurance,as required by Section
37 m(she Labor Code,for the performance of the work for which this permit is
i ed.My Wn Is a Co sation Insurance artier and Policy number art:,
Cvna F'e4�epolicy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'-
COMPENSATION
ORKERS'COMPENSATION INSURANCE,
I(This section need at be cnmpjcicd if the permit is for one hundend dollars
IEIW)or lcsxJ ,
1 ttrtpl than in the performance n she work far which his petite issued,1
shall not employ any person o any manner so as to become subject to We Workers'
Compensation laws of Colifdmia.Date
shit
ld
NOTICE TO APPLICANT Workin's ompe sate this provisions
of Exclaimer.you y umust r
Q Obecome subject y the Workers Compensation provisions of the Labor extol you must
(onhwith comply with such provisions or Nis perm:t shall h deemed revoked.
'Z) " 'CONSTRUCTION LENDING AGENCY'
a , , inti N
1 hereby re at Nene,iia construction lending agency for the pes(oee
W.,.., of the work for which this pets is i...cd(Scc.3o91,Civ.C.)
Q
..Lender's Name.. .. _ ..:
D Le dcr's Address
V 1 certify the 1 have real phis city
amnion and state thin the above:naw,relating is
coins.1 agfee I.comply with oil city end county ordinances and state laws enter
upc
D.V to building constrsetion,and hereby auNodze repmxnutiv<s of this city to corer upon
the above- tinned progeny for in ion
purpous.,
(Wc)a cumsEave,i mti y- 'd keep hatless the Cily of Cupertino against
F-tn liabiliticx,judg cora,cos dd cs us w ch may in any way seems against said
C.7 z. City in consd rcof graAtin fie, mdt. a //—Z7 J1/
50P1 CER 31 DE- ANDS D L COMPLYWIm ALL N .-POINT ' Issued by: Date / V
0
tgmrcofAppl ombe fat .Dat , Re roofs
HAZARDOUS MATERIALS DISCLOSURE
wet the apphcart ft b Iddg fa mprmt sin a thdie brow dare mmerm Type of Roof -
asdedbythe Cupertino Manicpal Cade Chapter 912and she Health and Safety vi t R - - -- -- - _
CodeSection 2553200? r s . . !'• t f.S l.S t s•
Cyr , - 'Wo, ..All roofs shall.be.inspectedpriortoany roofing-material.being.installed. ... ._.
W911 the applicant or future Wilding occupant use equipment at devices which If a roofis insiall6d without first obtaining an inspection;'I agree:to remove
emit hazardous air contaminants as defined by the Bay Ama Air QuManmm
agri
Do'it, all new materials for inspection.. Applicant understands,and will comply with
all non-point source regulations. „1 , ,
I hast ie thehez ux mac aL rtmemiunder Chapxr6.95 of Nc
CallV is Heult STfety.n e.sect: ns 5.25533 and 25514.1 unAers.andthat _ _ ...
if It it ing not cu tly have te t.But it is my msponsibility to notify she - -
fee I of s pts which u tact prior m issuance of Certificate of
Signature of Applicant -. Date_. - -
mmadaea.genr Date All roof coverings to be Class "B" or better
='
OFFICE .� ., .