05030179 CITY OF CUPERTINO �,.x»yq gw:�+myn ., •✓,' a t€ 'p,+j'
BUILDING DIVISION PERMIT ! ON, It A•1.�fRN7' 1; lVl' ' iQ>1� ;
BUILDING ADDRESS: PERMIT NO.
CAL-AIR INC 05030179
OWNER'S NAME: PERMIT ISSUE DATE
E; SANITARY N OLNO.
ARCHITECT/ENGINEER; BUILDING PERMIT INFO
BLDGELECT PLUMB MEC"
O
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 hereby afBtm Mad 1 am licensed under provisions of Chap,r 9(commencing p
n�2 with Section 7")of Divismn 3 ofthe Business and Profession Code.and my license is
o in full farce end if I / •s..L �� Pu O
5�3 License Cl Lle.Y 2 UNITS CHANGE OUT -
n Dam cunmom'
ARCHITECrS DECLARATION
Q;111 un&miand my plans shall be used u public recorM
?u. Licensed Professional C
D OWNER-BUILDER DECLARATION
iE I hereby affirm that 1 am exempt from the Consucsefs License Law for the J
o D following mason.(Section 713 1.5,Bmineu and Pnfeuioos Code:Any city or county
$g which requires a permit to construct,alter.Improve,demolish,or unfair any structure
'ZS prier to its issuance,also require the applicant for such permit to rile asigned statement
that he is licensed Furans.,to be provisions U dsc Conuacmr'a License Lase(Chapter 9 Sq.Ft.Floor Area Val 1
gg $ (commencing with Section?")of Division 3 ofthe Busineuand Prokandona Coda)or
1C ..
that he u exempt durefrom and me hue for,the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pemtB mbjeeb the applicant to a civil penalty of 3 7AB�b�OuP�f 0 0 Occupancy Type
not mart than five hundred dollen($500).
0 1,As comer ofthe properly,or my employees with wages in their sole compensation.
will do the work and meswctua is notimmuld orarfemA forsak(Sec.7044,Business Required Inspections
and Profeulon Code:The CnaacmYns s License law doAmt apply m er e an ownof q P
propertywho bulletin,initiatives Moment.and whodoessoil,snarls himse1farthrough his
awn employee,provided that such improvements An not Intended interfered fo We.If,
however,den building or improvement Is mid within one Win of cample0on.Ne owner.
builder will have be tandem of proving that In did not build or Improve for purpose of
.1e.1.
0 1,as moons of the property,am exclusively counseling with Iicz ned contractors,to
construct the pmjen(See.7044,Business and Professions Cade)The Cco,aclMs L-
ave law does not apply to an Owner of property who builds or improws titemon,and.
who convects far such pmjecu with a contrumr(s)liamed puatuani in the ComnemM1
License Law.
0 I em esempi ander Sec. .B&P C fm thts reasen
owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby&M m under Frothy of perjury as of me following declaration:
1 hem and will maintain a Cenifiaram te of Coto self-insert fa Wort sCompen-
ration,as provideA far by Section 3700 of rile labor Code.for the perfoonance of the
wort for which this permit is mued.
0 1 have and will maintain Wmkcfs Compensation luunnce.As requited by Section
3700 of the Labor Code,for the performance of the wok for which this permR Is IasuW.
My Wortef�Cymr��en2Na,nI unnce amu and Policy nu bar are:
Carver.lEXEMPTION Policy No.:��
CERTIFICATE PESATIONIFROM WORKERS' '
COMPENSATION INSURANCE
(This session most not he completed if the permit Is foram hundred dollen($100)
or less.)
1 certify that In the performance of the work for which this permit is Issued,I shall not
employ anypcison in any manner an As to become subject to th Wnten'Compenullon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenlfinu of Exemption,you should
buame subject In the Wortua Compensation provisions of the labor Code,you must
.7 Z forthwith comply with such Provisions or(his Permit shall be deemed invoked.
y CONSBUCTION LENDING AGENCY
[r Ihcunby affirm that them ler consuunlno lending genry or the Performance of
gy,s7 the work for which this Permit is issued(Sec.3097,Civ.C.)
til~n• Lender's Name
Q z Lender's Address
U Q I certify that I have mad this application and tum that the above Information Is
U.Htunnel,I Agree to comply with aril city and county ordinances and adds lawn relating to
Q V building construction,and hereby auhodmteprcumativuorthis city toenter openMine,
W ahwn-nimmned property for Inspection purposes.
(Wc)agree m sem,indemnify and keep harmless the City of Cupcnino Against
„y ji Ilabilitlu.judgments,con,ed expenses which may In any way acenen against said City
(„) in consequence of the$norm$of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S4VALEf Date
SOURCE REGULATIONS.
z 1 ?l1� Re-roofs
Sigaawrc aril Iieam" nowlm Delo
HA ARDOUs MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building Occupant store or handle harardous material
As defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Secure 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
GYoNo
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I haaunus air cnuaminanu As dcfincd by the Bay Area Ain Quality Management all new materials for Inspection.
District?
0Yur Nti'
I hat mad then havaunus materials requirements under Chapter 6,95 of the Califon
.in Health&Safety code,Section.25505,25537 and 25534.1 understand that if me building
does not curemly how a torn,that II is my reapommillty In n(%y t naupent of Ne
requlremcnuwc st Ipdnrin,suoceofeCcuOcmof .pancy. Signature of Applicant Date
14 NAOwren m smnari agent Dmm All roof coverings to be Class'B"or better