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CONTRAC`T`OR=TNFQI2MATIfOI:°
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
"""05080249
OWNER'S NAME:
PERMIT ISSUE DATE
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SANITARY NO. CONTROL NO.
ARCHI7ECT/P.NGINEER:
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BUILDING PERMIT INFO
BLDG E CT LU MECH
LICENSED CONTRACTOR'S DECLARATION
Job eseription
1 Mmby &M m Inst 1 am llmnsed under provisiom of Chaptar 9 (mmmmping
WIN seed.. 7M) of Division 3of the Busircss ane Professions Code, Anti my littnm u
In fullLiccforce and of %�J—%/L,��
NEW FURNACES/2 NEW A .0 UNITS
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o.ta cm
/NEW
MAR�'I R MEC AL, INC
' ARCHITECT'S DECLARATION
I mulcrsond my putts MJI be used u public mcord,
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from dta Con"clar's License Law to IM
fallowing maxon. (section 7031.5,' Business and Profession, Code: Any city or co my
which requires a Permit in conamon. altar. Improve, demolish, or repair any an me,-
poormitslasuance, also requires the applicant forsuch permit rile a signed state m
is licensed m the Contractor's License Law(Cltap
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Sq. Ft. Floor Area J
Valuate 0500
that he pursuant provisions of the
(cammencing with Section 7000) of Division 3 of the Business and Profauians Code) o
,`3"6
)
that he is exempt Wvefmm and Ne buts for that alleged exempdan. Any violation of
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Occupancy Type
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of.
not mese than Ew hundred d.IW (fS00k
9 3 4'OI n9 . () O �O?0
=9349,19
❑ L u owmr.f Ne property, or my wployw ww wage, a Nebmo eompewdon.
A}� ,g( pquired Inspections
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wiudo Ne w.rk.natMammmmi,tmtintaweaarnrtema mrwe(see.7Du,BaJ,tm,
and PnefeW.ns Code: The ComIHbM1 License Law does Ips apply In an M. of
property who builds m improves themon, andwho dmssuch work himselforthmugh his
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own employees, provided that such improvements eta not Intended orortered fm We. rt,
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however, the building or improvement is old within oro you of completion, the owner.
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Wilder will have the burden of peeving deet M did am Wild or Improve for purpose of
"to
❑ 1, M owner of the property. am exclusively com using with licensed mnbmtan N
construct dta pmjec5 (Sec. 70". Business and Professions Cade:) The Cordracpt, U.
cause law does not apply W an owner of property who Wilda or improv thereon, and,
who contracts far such pmjeco with a cen0ac,or(s) licensed punum in Ne Gmusumfs
License Taw.
0 l em exempt under Sao, BAPcr Nis won
GonerDau
WO PENSATIONDECLARAT10N '
1 hereby affirm under pmahy of perjury ane of tip folb ing d.d.dons:
I have and will mein Wn a CmificetaofConsem p self -insure far Wmkels Compen.
sation, u provided for by Section 3700 of the Labor Code, fm the performance of the
work for which this permit is Issued.
❑ I haw and will maintain Worker's Compensation Insurance, an required by Section
3700 or the labor Code, far the performance of out work for which this permit is issued.
My Worka(s Compensation Insurance mrtim end Policy num m:
Carder: Policy No.:
'
CERTIFICATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE
(Th6att51m need notbecamp cted Ifthe permit Is fortune hundred dollars ($100)
or leas)
1 unify that In the perle rename of the work for which this permit is issued. I thsil not
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employ anypemon in my mmncrw As N become subject tolM, n' o pe Lien
Laws of California. Data
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NOTICETOAPP CA ,af rmal� is m;Rcmc.(Exemption. you should
become subject in the Worker's Compensation provisions of the labor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 hereby affirm that dtarc i, a construction lending agency for use performmce of
do, work for which this permit Is iaamd (Sm. 3097. Civ. C)
'
Lender's Name
,
Iandefe Addw
1 «rtay that 1 haw reed this application and seta Nu roc aWve information h
corrin I agree to comply aids all city and county ordinances and sons Ins relating N
Wilding construction, and hereby authodm representatives of this city In enter upon the
alow-mentioned propeny for inspection purposes
(We) agree p rave, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may In any my someone Against said City
In eonsegnsnce of theiMMUS of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
7/
Issued by: Date "'Cl
SOURCE REGULATIONS.
Re -roofs
Type of Roof
SiVuturco 119mtlC6numtor Data
HAZARDOUS MATERIALS DISCLOSURE —
Will the applicant or future building ocmpantJmc or MMh hutrdous material
As defined by the Cupertino Municipal Code. Cbapmr 9.17. and the Health and Safety
Code. Sccd.e 25532(x)?
Yu �No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will dsc applicant or room building Occupant Am equipment or dcvlces which
t hoodoo, aircmumboanu As dcflncd by the Say AMA Air Quality Management
all new materials for inspection.
District?
❑Yes A&
I have mad the hpardous materials requirements underCMpmr6.95ofthe Califor.
nia licalth K Safe,yCodc. Secdons2551)5,25533 md2553d.1 understand dwifthe Wilding
does not mumndy haw a ¢mm, that It u my responsibility in notify tM occupmt of roc
myulmmenu which must be met prior issumceorsccrdnesmofoc
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or Authorized agentDate