02080125 CI BUILDING OF UDN
PERTONO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10223 RANDY LN FOUR O EIGHT HEATING & COO ING02080125
° P AVAn APPLICATION A
ISVANATHAN 6258 GARNER CT 08/22%2002
\ PHONE: (925) 461-3333 SANITARY NO. CONTROL NO.
C Z z ARCHITECI9F.NGINEER: a BUILDING PERMIT INFO
o
kL" BLDG ELECT PLUMB MECH
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Z 17 w z LICENSED CONTRACTOR'S DECLARATION Job Description
Z_ 1ior7 hereby affirmthat Iamlicensed under provisionsoi e,Core.andhapter 9 myliceing REPLACE FRUNACE
Froa with Section 70[10) (Division}of the Busines an xprofessions Cotle.and my Iicenu
n fu
o � «er.�421RCt.11C
[Fil\IALE®
ate con for
.9 a T'S DEt CCL�_f/IO
h I=0 g erstand my plans shall ba used as puTlfc recoA� SEP 2 D 2002
4�i
as d OC Licensed Professional
OWNER-BUILDER DECLARATION
I hereby aRwnn that I am exempt from the RATIO is Liana law for the �y�
t:?< following notion.(Section 7031.5.Business and Professions CodBUILDI,�jZ\
Code:Any city or county J 0
which requires a permit to construct,alar,improve,demolish,or repair any structure
ad 3m poor to its ismance.alw requires the applicant for such pematto file aigned statement
ex [bathe llacied Puisu'ht 16daTzroLSIonsofthe Contractors Lmcrue Law(Chaper9gr Valuation
(commencing thSwic 7"1ofn Division ,1?-t�':•xon3oftheBusinessandProfessionsCnde1 {'a'sx' ;31 12 O B?!��FFa� M
or that he is exempt thertfrbm and the basis for the alleged uempthm Any violation -
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(5500). 301APN AlginkM PLUMBIN "' ' ' Occupancy Type
❑L.as owner of the pmpeny,or my employees with wages as their sole compensation,' 303 C
ROUGH ME
-will do de,work: ad the ode:spoliate ms Contractor's License
o Law for zale'(Spl in W.
an 3 04 - ROUGH ET�+^WRd(f Actions^
Business and Profession Code:The is n,intens oro Law Jars rat apply man '-'+"cf "a'f°1' '
owner of ,.,.y Who Wild,or improves ummoh,and who does such work hirmel f 505 - FINAL ELECTRICAL
or through his own employees,provided that such improv stems art nm intended or .- - ---- ....
-offered for'mW If,hawevcq the building or improvm
eent is sold within corm year of 507 - FINAL-' PLUMBING , . .` ' •' -• r
completion,the owner-builder will have the burden of proving thin he did not build or
improve for purposr°f sale.). 508 — FINAL MECHANICAL
_., .. _.. pert ..._xclusi ------"'ce - -
o ha owner of the property.7(am Business and era examing stCo&:)uJ,Contrast s `..• .
_ <onaw<t athew projectno(Sec.70Ja.owncrsa arta property
who
codc:l Thc improves
[hemi s
Licenu law does not apply loan owner of a comm who builds se improves thereon,
_.and.woo commets.forsucb projects with.a.commnor(s).licensed punuanem the. _ � ------- --- -
$rtnnors License Law. _ - - __._—..._.__.._.__.____.__.—....._...__-__.._.._..-___ __.._.____
fl l am exempt under Sec." 8&P C for this reason Ic""l'^i' t!`
Gwn a ,
WOR— KER'S COMFCHSATI NDE WRATION
I hereby affirm under pcwhy of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to ulf-insure for Worker'x
x. Compensation, as provided for by Section 37W of the Labor Code, for the
p<rfommnce of the work for which this permit is issued.
01 have and will maintain Wmkcr's Contpcnsatiun In uran2e,as required by Section
'37W of the Labor Code,for the performance of the work for which this permit is
"` '� i cued.My Worker's Compensation Insurance artier and Policy number arc
Wit., p.`t-rk.., a - .. .. ... ..
-11,1 ;CERTIFICATION OF E%EMPTION FROM WORKERS'- '. �:^4'� •I•\� +`.r lx a (*x j 7i'. till�.x
... COSIPENSATION INSURANCE_"••'• ` _, .. __._pert. .—_-_.___I, ,\.___...___......._..__-____....__.__--I__.__...._..__.____ pert._..—_. _ _. _pert--------
(This
rt_.pert(This seschni need not becomplemd if the permit its for one hundred dollars •I "ldls" •c.t`"
(Sl Wl air l<ssJ
I n fy that in&p rf f th k for which th pc t is...
ed 1 ,
shall not employ any pe y iS/rx{ �rj,x�s M1je t m the Wo kers
rrr�rh OIQt�y/-
p...I rola ,of�Gloom -
Co fl
APIA _ .. _ .. . .-.
IT A LICAYP,IC afmr making this Certificate of Exemption.you should "
Q O 'ba bl'tio lh<W k C pcnxat p haofdesind!Cade you mus
forth lh c ply with such p '.'ins or thism t pershall bee ticcmed revoked.
�.V) CONSTRUCTION LENDING AGENCY,
> which I hereby affirm that there s on w t [ending agency for the p"t8or aree '
W .. of the work for this permit is permr4ntv.C.)
issued(Sec.3097.Ci ---,--_.-_-, -,--,_
lZ 0 Lender's Na me which .x........ _. _pert .__.. ..... -. . .. _ ... .. ... ._pert ...pert ..__. ...
Q Z Lent<r's Address x - ,, __
V 1 certify tom have rah This application and ante that%and stat information is
-fiat+. cn build 1 agree to comply with all city and county oNiatives and sine laws elating
0 W the building feetyautoorire rcinsenmtives'of thiuitymcmcr upon
= the abolWel tine m properY for i y Arid on purposes.
•rat L IWjudgme to savct and a pensesk hi h may in the way accrue
against
i id
h liabilities,judgmen6 Cosa rain r,id,
i which may in any way accme against aid
_V z
City inconsequence lit the NDS A of Ibispermit.
APPLICANT UNDERSTANDS AND WILL COS1p1 Y WITHALL NON+POIbT Issued bASU Date
' SOUK YA
mum of A,hs.nVC°mracmr Date'-' Re-roofs
�, HAZARDOUS MATERIALS DISCLOSURE
..
Will the a,licamo,n building eceupam sore or handle n som.,material Type.of Roofas d f ed by theCupertino Municipal Cho Chapter 9 1i,and the Health and Safety - t
Coda.Sermon 1557111 7_ t • '' -• - t'r;:•:r�A j k f a!!r'y
'moo, x I. 4h III - .. i1
°Yea'' All roofs.shall be,inspected prior to any,roofing material being installed.--, -
.Will the applicant or future building occupant us a quipmenlordeviaswhich If a roof is installed without first obtaining an inspection, I'agree to'remove
emit hazardous air mntmninant,us defnod by the Bay Arca Air Quality Management
District' allpew materials for inspection. Applicant understandsand will comply with -
oY" all non-point source regulations...
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505.25533 and 851x.1 understand that
if the building Joao not concolly have a lerso0hat it its my responsibility it)notify the
dccupant of the requirements which mos tie met prior to issuance of a Certificate of
occupancy. . Date
,.. ,- � Signa_ture_ of Applicant . _ . --.
r.atnodrpa agar,. ' D All roof coverings to be Class"B"or better
:: ,•'
_._.
- OFFICE ,