01040054 TY
CI
BUILDING U DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADORES£ PERM I'1NO.
3 RED FIR CT PHOENIX HEAT AND AIR 01040054
OWNER S NAME APPLICATION SUI{DATE
ANTHONY DIKEEFE 725 RODGERS AVE 04/12/2001
l Plnosdr: SANITARY NO. CONTROL.NO,
BUILDI PERK5r INPII
O O AHCHITF.CI'IF.NGINEER: - BLDG ELECT PLUMR MEC
W—
6°
S 3 LICENSED CONTRACTOR'S DECLARATION Job Description
Z:' 1tion7 aliimn that Tom Ld'helli under pro visionsof Cnapmr 9(commencing
with Section 9lXNpaf Divi,ionJ of tha llnuingvx and Prnrcvuinn<CuJe.andal,license
1:ayaC Inli,ur,)It C, f"t FURNACE & A/C
iicemyc'" ` -'L(� Lie. 6Blb
O e.�' Da¢_ ti 6 Comnnor N is+
3 W y ARCHITECT'S DECI.A I'll N ar
I ander,mind Ypl hll beused . pbl' ds 1
a6p� I:cc Jlr f:. 1
OWNER-BUILDER c,seDthe ConIION
—— I hereby (t th I 1 pt 1 the C t « : 1 far the
C h i 411: g. (e ( 71130 9 I3 :' n 11 1 Code:A y ay ,,only
Z2Le Inch thL;hv, npovu,dcnWlh. file augany sm,nent
u�6f3n then hesliclnuance.alss,atat thnhovisiocanitia rocsmants Linmw1,a (Cleapenl
mat(commencing
pSectio ,,)the pm,Nd,)nsn 3 o Conlructors an nsclnssion% net9 'Sy. Ft. Floor Area Valuation
in Irt,her,
c vnlpt Section 7000)nfhe Is,in lot
BushT.1 Lmaptind .,Any ns Code)
o,ran ne'Ls esemmt Inercu,)m and ma osis(m roti aneged esclmnion.Any vn,lar,)n e '
nr Section 7031.5 by any applicant Ib.r ponitit ua,jena the applicllnl In a civil penalty
of not more than five hundred dollars(S500). APN Number Occupancy Type
El 1,as owner Oahe property,or my empldyees with wages as meirsole comprnsadon, 35 e
will do the work.and Inc structure Is not intended or offered far sale(ties.70,W.
Boniness anti Pndeoiom(isle:The Contractors Ishan(Law,docs at,[al,l,ly to vn Required Inspections
or thr u(plenary Who b,ilds or impnwes Ihercan.and who does such work hint.wil
rough his own employees.pmvded that such improvenems am not intended or 301 — ROUGH PLUMBING
ofared for sale.If.however.the building or improvement is sole within one Year of
nmpletion:menwner.milder will nave the bemknof proving but he did and build,), - 303 — ROUGH MECHANICAL
improve ser.....sec of slue.).
❑1.ismsnerof the property.amesclusivetycontracting with licensed commetoma, 304 — ROUGH ELECTRICAL
construct me project(See.nua,Busine s and Profession,Code:)The Cottemor s 505 — F I NAL ELECTRICAL
Liucnse Law dols nor apply to an owner of property who builds or ilnprovcu memon,
sad wit()comm«, B„saw probers vol,a contmcroasl.ficensed mlrsnnnl In the
507 — FINAL PLUMBING
oirmeveril a sa: 11&PC Ratio,reason 508 — FINAL MECHANICAL_
Owner 1>m
WORKER'S COMPIiNSAIION DECLARATION
I hereby affirm under penalty of perjury one of the following declafnliom:
l3 1 smc z I will incorion a Certifcmc of Consent It,self-insum lin Woder'x
CoraPosulion, m provided fel by Srcu( 371H) of In Lubar Core. he (be
redLrmanee of the wink for which his permit is,,uvl.
❑I haveantiwill immune e Worker's Compensation Insurance,as required by Section
970(1 of Ibe Labor Cade,for he pedorinance uI the xork or wnwh this purmit ix
sued hty Wader's Com enwtion Insurance carrier and Policy numher ore:
Carrier: N— ea.-s- 'so icy No.:p.t q 13 23 I
CERTIIIC�ArII N 0 r F.XIiNIPTION FROM WORKERS'
CU IVENSA'1'ION INSURANCE
(Thi%section need not be completed If the permit is for one hundred dollars
41 BB or les,.)
I ecnitp Thar in the,L,for oval of the work far which Ihl,permit is island,I
,hall in.,employ any Iemnt in any manner n,as e,saloon subject it Thu Worker,
Cure ennalion Lew,of Coliforms.Use
Applicant
NOI CIT TO APPLICANT.If,after nakmg this Certilicale m1 Exemption,you s houlJ
Z becamenal,joa ,he W..kers Cmnlenseoon pm sit inn(roe Labor Cad"younaa
OIbnhwllh comply with suit pro oinns or this permit,ha11 be devoted rcvokcd.
z O CONSTRUCTION LENDING AGENCY"
a ' I hereby affirm that them In a contraction lending agency for the performance
d the wink for which this pem,il is issued(See 3097,CIv.C.)
L Q Icnder's Name
= Z lomlef's Address ,
V O 1 amity the,I havo mad this applicasm and slum lneuhm above ink ortmtion is
La., neer.I agree u,round,with:dl Illy and am a,mdoleal,and vale all mlering
mbuilding c auction.sad nrmby entborizc representatives of this city to enter upon
•�„ y he abort-mcntiomed property fornoemom puHs,ua.
r p„
(We)agree to cave.indemnify and keep harmless the City of Cupertino against
Z City nice,judgments,cnnu and upcnscs which n,vy In any way uccnu;against svid
L.1 Z City in aonncyucnce of the granting of I to permit. _
APPLICA 'NDGRSTAN��SAyJ�WILLCOMIWIy"�- �ON�POINT ISslledb Dale
01
Le Y-lz-09 y
a nrnpphemnrc-yt�pr, 1r„te Re-roofs
IIAZARuDUS MATERIALS DISCLOSURE
Wlu me applicant or hatim building tecmpanl store or handle 1,norsh,us Loom al Type of Roof
as defined by the Cupertino Maddpal Cade.Carl 9.12.and the Health and Safety
Code.Section 25532O7
ores Cl No All roofs shall be inspected prior to any roofing material being installed.
Will applicant of future building occupant use eyuipmenr or devises which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit humidors air(:mammoths m defined by the Bey Area Air Quality Management
.D:su'l all new materials for inspection. Applicant understands and will comply with
ClYet 0 N all non-point source regulations.
I have mad Inc hunn dors nm em.1,myaircmems under Chanter 6.95 of Dna
Cullman.Health F Safety Cock.Sections 25503.35533 and 25531.1 undersand Phut
it the building docs not currently base it mount.that it is Iny responsibility to notify,he
ucaupant el the re I.aom,L,wb(.It at be e ill a Certificate of
terminal Signature of Applicant Date
6an,n,;,Id;,gcrT Dam All roof coverings to be Class "B” or better
'ItOFFICE