04050035 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON'CRA.CTORXN�'UtMATTU�," ,'
BUILDING ADDRESS: ENVIRONMENTAL SYSTEM INC PERMIT"°04'050035
19111 P
OWNER'S NAME: PERMIT ISSUE DATE
HEWLETT PACKARD 3353 DE LA CRUZ BLVID 2004
E:
SANITARY NO. CONTROL NO.
(408) 980-1711
ARCHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
uOZO LICENSED CONTRACTOR'S DECLARATION IobDescription
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7M)of Division Sof did,Burmins aM Profession;Codi my]team.is
in0rrsfo..andefrom TI--REPAIR CHILLER
Z Lice..Class Lia.is
Data Contractor
a ARCHITECTS DECLARATION
Y H 1 understand my plana shall he used as public records
D,u ,
u,t; Licensed Professional
S OWNER-BUILDER DECLARATION
.
in X I hereby affirm that 1 em exempt from the Convector's License Law for the
O O following mason.(Section 7031.5.Business and Prons fessioCode:Any city or county
K$ which requires a psomil to en stout,alar,improve,demolish,or repair any someone
F^�^ prior m its issuance.also acquires the applicant for such permit to file a signed statement
FZ< that he is licensed pursuant ntru
JpursuanotheprovisionsoftoCocwr'sLkcn.law(Chapter9 Sq.Ft. Floor Area Valuation
y FCS (commencing with Section 7000)of Division 3 nl NC Business and Professions Code)or
3^ that he is exempt Nemfrom and she basis for Na alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicmt 10 a civil penalty of
not more than five hundred dollars(5500).
PIO 0 Occupancy Type
0 1,as owner of the meruny,or my emplayces with wages as their sole compensation.
will do the work and to structure is not intended or offered farm].(Sec.7004,Business
and Professions Cade:The Commcmes Llcemt law does not apply in an owner of Required Inspections
property who builds or improves thereon,and who does such work himsel f or through his
own employees,provided that such impowanden l arc not intended ordained for sale IL
Winton,the Wilding or improvement is sold within am year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
'as owner of the property,am exclusively convecting with licensed contractors m
onstons the project(Sec.7044.Business and Professions Code:)The Convector,Li.
came Law does not apply to an owner of property who Wilds or improv thereon,and
whocomsa c with a canwctar(s)licensed pursuant o tie Carmine,
OLI�mR<;aeµ drSa.
__
I .B kPCfar this meson
Owner — Dea
R COMPENSATIONDECIARAI
I he under penalty of perjury one of the followi .luedons;
have and will maintain aCari f¢aa of Consent m self-insum for WoracesCompen-
sation,as provided for by Section 3700 of the labor Cade,for the performance of the
work for which this permit i,issued.
0 1 have and will maintain Worker's Compensation Insurance,as mquimd by Studien
3700 of the labor Code,for the performance of the work for which this permit is iuucd.
My Workers Compensation Insurance turner and Polio number am:
Carrier. Polio No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissecabon meed not W completed time Permit s forom hundmddnllars($101)
nr less.)
I certify that in the performance of the work for which this permit is issued.L shell not
employ any person in any meaner an as to become subject in the Workers'Compensation
Laws of California.out
Applicant -
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Q Z forthwith comply with such prnviinuns or this Permit hall be doomed invoked.
„'Zy rA CONSTRUCTION LENDING AGENCY
Ihereby affirm Nm there is a construction lending agency far the perform,nce of
Ri> the work for which this permit is issued(Sec.3097,Ci,,C.)
QLenders Nunc
Q z Lender's Address
U Q I certify that I have mad this application and stale that the above information is -
{f4 correct.I agrm to comply with all city and county ordinances and arae laws misting to
Q(J building construction,and hereby authoris,mpasentatiscs ofthiaeity to enter upon the
W above-mentioned property for impecima purposes.
gL (Wry)agree to save,indemnify and keep knormss the City of Cameroon against
r IA liabilities,judgments,ensu and aspens which may in any way accrue against mid City
V`L in con of this Permit.
a" APP [ANT R DS Li:COMPLY WITH ALL NON-POINT Issued by: Date
SOU F v
Re-roofs
Si urc Appi ant Dam
I DOUS MATERIALS DISCLOSUIIE Type of Roof
�114114b pplicam or fmurtbuilding occupant store or hair arardoua materiel
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code,Section 25532(q? - All roofs shall be inspected prior to any roofing material being installed.
❑Yes g
Will the applicant oAn
fuwrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
islflCl?
0 Yea
I have nusm quisn" "uadcrChapur6.95ofIWCalifor-
niaFMalth& LYC ec' 255 SJ]and255J4.1 upticrsmntl lhafthc Willing
does not curmal a m di P, Il is m I lty m notify the occupant of the
reyui`mawgw must mfr or uanccofaCcniOcatep�CcTmcyy. Signature of Applicant Date
jj -, &
Owner or amhatlzrbag rte Date All roof coverings to be Class"B"or better