00090094 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRCSS: PERMIT No.
OWNER'S NA IE0415 PRUNETREE LN AIR N, 1
APPLICATIOA u
ONE IRIS IMRDRt N AVE SANITARY NI. Ole' 190
O M]. ARCIIITL6TAS\GIN6EH:- 4 ..t BUILDING PERMIT INFO
FOO BLDG ELECT PLUMY MECH
u
�n
LICENSED CONI RAcFiR'S DECI.ARA'rION Job Description
1 heathy nfhrm that I am liccnud under provisions of Chnmcr 9(conuncncing
F=t_w want Section 7000)of Division 3 ofthe Businew,and Prom,ioms Lure.and my license
¢re e S: is in full from and effect.
_n W-< DaLie..
m.ecla.x A/C FURANCE CHANGEOUT
3O a a u Dice Li,# r h ARCIII'I'CC'I"S DECI,ARAIION
I uudesmntd my plans shall he need os publle records
i a o i0 Licensed I'rofesaiowl
OW'NI'.even -BUILDER Iyf:C1.AHATION
n1 I hereby affirm that I nm exempt from the Cnnv.Our'n License Ww far the
1—% billowing nano).se,6on 7031.5,Bmincw and Profis,iom Calc:Any db'or county
c�O
which Ii 1coutht t,a1mr,antarove.6ciaolish, p y.-mmrre
cepnort t''. 'I. t1
: e' .�
Irl tf 1,p,unifto II asigned'Inacal
c. that heislicensed pursuant t the pro,reorr,ofth C t tor's License Use(Cletlaer9 Sq. Ft. Floor Area Valuation
(commencing with Section]IMP)of Do Wim 3 of the Braine,and 1'ntfmssions Code)
or that he is exempt themfmm and the basis bar he alleged exemption.Any vimmion _
of Section 7031.5 by any applicant for a recoil subjects the applicant at a civil penally n
Occup! c
or am mare than me hundred dollars($50()). APN Number
❑I,axuwmerml'the nrapu ly.or my employes,with wnpev'to'l rsole contpen"dimn,
will do be week,and the structure is not intended or offcrel for sale(See.9044. 31 6331.LAG I ed inspections
and Professions Gdc The Contractor's License law does not apply m on
owr,of progeny Who builds or improves hereon,and who does such work himself -
or through has own employees.provided that.such improvements are not intended ser
uttered be arc.If,however,me building m intpravenear i.sold within one rear of 303 — ROUGH MECHANICAL
mTletion,due owacnbuildar will have the btudca of pmviny that he clod not build or
`Gnprove for arrow,otsWc). - 304 — ROUGH ELECTRICAL
❑I,as owner or the progeny.am exclusively commeting with licensed contraeors at 505 — FINAL ELECTRICAL
Latnwct the project(Sec.9004,Business and Professions Code.)The C.M.ter-s
icense law does not apply to an owner of property who Molds or improm.heron, 508 — FINAL MECHRNICRL
and who contracts for such projects with a tontrucmr(O dicemvd pursuant to the -
Contraauu'e license Law.
❑1.,it cvcntpl under Sm. .If Ar 11 C for this mucro
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one ob the following declaratioaec`�
❑ 11 I '11n t aC tlat IC . to ell , f Work,,-s v/
Con pt li
c pn I 1 I by Section3900 of (lie Labor Code, ft the
<��
pert m fork lor which this permit is'sued /
❑1 have and will maintain VVk Com,Penvidion Insurance req -mel by Section
3900 of the LAxa Code,for the performance of the.ntrk our which this rani t Is
sued.My Worker's Cenlemcxtion Insurance carrier and Policy nmaher arc:
Cartier: Policy Na: -
CERTIFICATION OI'EXEMPTION FROM WORKERS'
COMPHNSAI'ION INSURANCE
This.ection need not be completed if the Permit is list tine hundred dollen
Sirloin Its..)
I cantly that in the lerfocnante of the work fin which this penult Is is.ned.I
.hall not employ any person in any manner so as to become suhjecl to he Warken'
Comps nsmion law.of Ci liftomit.Date
Applicant
NOI 21 ro APPLICANT It,after ren um,fats CcNfame of l?.emptlon,you should
hecmnesah,i.c ahe W..ker'.Cminpensmioa Pmvi.mnsof dm e a
Labor CodY ..malt
Q Q bmhwih comply wih.such pmvi,nos onhis pe shall be dccrmd revoked.
CONSI'RUCfWN LENDING AGENCY
> 1 hereby a1Emr that there is a construction lending agency for the performance
W of he work for which his permit is issued(Sec.31199,Civ,C.)
L Q Isndds Name
.Q z Lender's Address
U C 1 certdy that I have rend his application and state that the alawc inforn miou is
ra. F. correct.1 agree at comply with all city and county ordinances and state laws relining
[) mFuilding rnnsauction.and herby authorize reprevenmrives of this city m cnerurym
the uMtvcmemioned property for in"e ince purpoars.
iy (Wc)ugrecrosave.indemnify and kap harmless the Cayor Cupertino ugaina
Vi liahilhic.jnd"aluts,coax and expcnees wldch may at any way neer...ngninst as d
V z City in consepmnce obthe l u diuta 91 This In'nnil,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
SOURCE REGULATIONS.
Signature tib Applicamo
lCtmmeor Date Re-roofs
HAZARDOUS MATERIAI S DISCLOSURE
Will me applicnm or lourc building occupant store or Lucile halarmaV m::terial Type of Roof'
o Refined by me C..pceino MunlelPal Cuda Clugt¢r 9.12.and the aadlb and Safety
Code,Section❑Yes 25532DC! ON.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future budding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
.mit hazardous air conmmimanh a.ddined by the Bay Area Air Quality Management
District! all new materials for inspection. Applicant understands and will comply with
Yea 0 No all non-point source regulations.
I have read the bmwom us materials requiremenrs under Chapter b 95 0l the
Critter niu Health&Safety C We.Sections 25505,25533 and 25534.1 understand that '
ifrhe buildingdas not currently ham a mrmm.that it is my resprmsihility to notify the '•
occupant of the asquirenreas which most be net prior to i.sta nee or a Cen Rico a of
D.eap'aaey. Signature of Applicant Date
Owncror authorized agcm Date All roof coverings to be Class "B" or better