03010062FA
CITY OF CUPERTINO
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CONTRACT"OR INFORMATION Edi
BUILDING DIVISION PERMIT
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BUILDINGADDRPSS:
AAA FURNACE & AIR CONDITION
ENI NO,
10385 PLUM TREE LA
01010062
OWNER'S NAME:
1712 STONE AVE
APPLICATION SUB DATE
AHERN JAMES M AND MARILYNN R
01/10/2003
'ONE
(408)293-4717
SANITARY NO. CONTROL NO.
ARC] I fll?CDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACT'OR'S DECLARATION
1 hereby 1 licensed Y
Job Description
affirm that am under provisions of Chapter (commencing
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Seetion7N ) Orvision3of Ne Businessand n(essiorm Code.and my license is
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License C_Im Lic. z
ADD 30, 000 BTU �n
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ARCHITECTS DECL ATION
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understand my plans shall W used as public records
11
JUL 2003
LieensedProfessional
OWNER-BUILDER DECLARATION
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1 hereby affirm that I am exempt form the Contractor's License Law for the
following reason, (Section 7031.5, Business and Professions Code: Any city Or county
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'LDIPI^
BUILDING
: $ �
which requires a permit it) construct, alter, improve, demolish. nstouter,
it repair any struc
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�ieprion,,
its issuance, also requires Ne applicant lmsuen permit m file a signed statement
that he is licensed the Ofthe Contractor'..xLicenmLaw (Chapter 9
Sq. Ft. Floor Area
$3YO@ation
purauanuoprovisions
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c1 Ung with Section 7(ggp of Division 3 of the Business and Professions Code) or
Nal he i,mmencs exempt therefrom and the Was for the alleged exemption. Any violation of
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Occupancy Type
Section 7031.5 by any applicant for is permit subjects Inc applicant m a civil penally of
not tune Nan Ove hundred dollars (5500).
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Ne propeuct
do the704,1. Business
remyemntendedwithwagoulhei(Sm. Business
structure
will dmhewok. ands:
oroffereddoe
—R055 IG
Liens
Code: Tic Contractor, License law dna not apply to an ower
is not apply to
and Pny
303 - ROUGH &AVons
eny who impmvsuthereon, end who dos soh mink h ,.fifes Nmugh his
who is
.a s. provided If.er-
intendedmpleteud fire
rn
304 — ROUGH ELECTRICAL
is said wiBaune
however, Thees.inornprwmech
builder, Nebuildingorimprovementishold within one year of completion. fire Own
505 FINAL
builder
buiWcr will bars the burden of proving Natbedid not Wild or improve for purlmu of
purpose of
- ELECTRICAL
sale,),
507 - FINAL PLUMBING
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
508 - FINAL MECHANICAL
ceramic, the project (Sec. 71W. Business and I4rfessions Code:) The Contractors Li.
ceme Law does net apply to an Owner of property who Wilds or improves Neat and ,
whit contracts for such projects with a contra ou(s) licensed pursuant to the Contractors
License 1. w.
❑ I am exempt under Sec. , B A, P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to ul6imure for Worker's Compere
sation, as provided for by Section 3700 of the Labor Code, for the per(nmance of The
Work for which This IMrmil is issued.
dal have and will maintain Workers Compensation Insurance, as required by Section
r1 of The Ichor Cole, for to Performance of the work for which this permit is issued.
Worker's Compensation Insurance carrier and Policy number am:
Carrier Palm1y7�R,: .�///.��J/.//�'A'[ d
C•RI IFICATEO E) PTI ONiROMWORKERS'
COMPENSATION INSURANCE
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(This section need nm becompleled If Ibe permit is for one hundred dollars (SI00)
or less.)
1 certify that in the performance of The work (or which this permit is issued, I shall not
employ any person in any manner w as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making This Ceniticate of Gumption, you should
became subject to the Worker's Compensation provisions of the Labor Cole, you must
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forthwith comply with such provisions or this Permit shall M deemed revoked.
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CONSTRUCTION LENDING AGENCY
hereby affirmNal There is a crnsuuction lending agency lin the Performance of
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the work frit which this Permil is issued (See Nall, Civ, C.)
Name
QLender's
Lcndcr's Address
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I certify Thai I have read this application and stale that the above information is
f-'
coned. I agree to comply with all City and county ordinances and state laws relating to
building cOnsmiclion. and hereby autherive repnewhatfiveh of This city to enter upon the
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above mentioned property for inspection purposes.
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(We) agree to save, indemnify and keep harmless the City of Cupcnino against
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liahilitics, judgmenu,costs end caperrui which may in very way accmc against said Cily
ineonuquenecofthe 6ran,ing r(This permit.
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
Issued by: Date �O
SOURCER G LATIONS.
Re-roofs
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fApplm/Co sur �aDatc
HAZARDOUS NIATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building Occupant store or handle harallous material
as defined by the Cupertino Municipal Code. Chapter 9,12, and the Health and Safety
codr, section 25532(a)r
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All roof's shall be inspected prior to an roofing material bei,,
P P Y g g installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
veil hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑Yos No
1 havemad Nenaaardoloma¢ Chapmrfi95o(Ne Calling
5.25quire 255under
I building
riastealthtaSatcty Cade,Sectionsn.' 2my
nam12553d, In mad, UThvi(thc
it 1
hats a ¢rant Na, it is my respamihiliry In notary Ibe occupant of Ne
does not cues
whic
regain cn 1which must W met prior m kcauaneerf a CsniOca¢ofO:cupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
D mane agent DN t
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