01090116 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20599 SCOFIELD DR 01090116
09/26/2001
PHONE: SAN IARY NO. CONTROL NO.
l
O O ARCHITECTIENGINEER: BUILDING PERMIT INFO
m❑ BLDG ELECT PLUMB MF,CH
LICENSED CONTRACTOR'S DECLARATION
i u C 1 hereby nRrm that 1 am licensed under provisions of Chapter 9lmmmendng Job Description
z f=ro .with Section 7[XXB of Deni 3 nnh<Baainesa aha Pwreaamns code,aha my fmnae FURNACE & A/C.
$m 2c is in full force send eliecl,� 2 Q i- 2-
rs0 u U License lazs C Lie.x
Da¢ Convector
1 4 u.�r p C 1TECr'S DECLAR
g 1 understand my plum-ball w used as mblle ret rds
76 T
3 rc p Licensed Pwfeoncoull
OWNER-BUILDER DECLARATION
tt�`= 1 hereby aRrm that 1 am exempt from the Cmuacwr's License Lw for the '
C5?< following reason(Section 70315,Business and Processions Code:Any city or county $9210
N O which requires a Permit to construct,alter.Improve.demolish,or repair y structure
i3m prior to itsissuance,also eq r the pplicant for such Permit to Ek aligned
- nateem 1 _ _ ..
Nathelidpantt'theprovts sofmeCoimcioes LicenseLawIChms, 9 Valuation
(commencing w thSecti nTom)ofDiai.mn 3onhe Businessland Pr4re3:onsCade) COO N ;'r3 �9'A $(er,61s
or that he is exempt therefrom and the basis for the alleged cennpuon.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of a.amremamfive handrail dollars(s5m). 301p'pNilAlft$ PLUMBIN �' ' Occupancy Type
❑I,as owner of the propurty,or my employees with wages as their sole compensation, 10 1 — ROUGH ME
will do the work.and me structure is not intended or offered for sale(Sec.7044,
Business and profession.Code:The Contractor's a«nae Law d«a hat apply m an 304 — ROUGH E1WQMM@3*ctions' ' '• ""
awrte rofpropenrWhoWildsorimprovesthereon,and who do<nsuch warkhimself 505 — FINAL ELECTRICAL
or through his own employees.Provided Nat such improvnn sol are not intended or
offered ion,dic ICeomuever.the waning or improvement is aIle he did ane yen or .. 507 — FINAL PLUMBING
completion,m<owner.buueer veal ossa me wraen or Proving mat he aid riot wile or
improve rarpurposeor.me). 508 - FINAL MECHANICAL
❑L as owner of me pr.,,,am<xdasivelr contracting with licensed contractors to
construct the project(Sm.7044.Business and Professions Code:)The Contracwra
License Law docs not apply w m owner or property who builds in improves thereon,
.and who contracts for such pwjacts with a contractors)licensed pursuant to me
Convenors License Low,
❑l am exempt under Sec. .B&P C for this¢anon I
Groner Dote
WORKER'S COMPENSATION DECLARATION >X
1 hereby affirm under penalty of perjury one of the following declarations: .
❑ I have and will maintain o Certificate of Consent to self-insure for Worker's
Compensation, as'provided for by Section 37th of the Labor Cade, for the
perfarmwmce of the work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as mquimd by Section
r. 37th of the Lwr Code,for the performance of me work for which this permit is
'u' C issues.My W rs pcnuil. Insurance carie d Po umber art:
r•,-
t CERTIFICATION OF E%EMPTONFRO WORKERS'I
_:... . ,.. ._ COMPENSATION INSURANCE
"1 taciturn ciiodncering he eompincE iftha permit is far one p
hundred dollar; si:t:;)L" '.
(5Im)or lista
I certify that in the performance of the work for which this permit is issued,I
shall not employ any person in any'manner sa as to become subject,o the Warkera'
Compensation Laws of Califamia.Date
Applicant. I ... . -
N TI'ICE TO APPLICANT.,IL after making this Cenificaw of Exemption,you should
Z. became subject to the Workers Compansation provisions of the Labor Cade,you must
QC forthwith comply with such provisions or this permit shall be beamed revoked. 1
H'y t CONSTRUCTION LENDING AGENCY 1' 1 'f
a ' ' I heteby ri firm that than:is.commuction leading agency for the perfoimanee
i
of the work for which this permit is issued(Sec.3097,Civ.CJ '
(] Lender's Name `-
_.Z Lender's Address
V Q 1 tinily that 1 have read this application and state that the awve informnion is
W [r correct.1 agree to comply with all city and county ordinances and state laws relating
O.V to wilding contraction,am hereby amhoriae repocomatives of this city to enter upon
;s, me.rove-memfaned propary far inspecdan proposes.
�.L (We)agree to save,indemnify and keep harmless the City or Cupertino against
to liabilities,judgments,costs and cnpemes which troy in any way,acme against said
U Z City in consequence of the gmatin of this t. '
i••' APPL NT UNDERSTANDS DWII YWRHALLNON-POINT Issued by: Date
UU REGULAT�NS. Y:
Stg of Applmnm/Contmcb.l Dene
,t. . HAZARDOUS MATERIALS DISCLOSURE Re-roofs
tam the apybe.at or Iran wildimg wompant stare ca barrels hara,dms mneriat Type of Roof -
az defned by me Cupertino Municipal Cede,Chaptcr 9.12,and the Heald and Safety
Code,Section 255321ai7.
❑Yes "oho I. . All.roofs.shall be inspected priortoany rpofing.material being installed.. . .
iW-il)the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection', Fagree to remove
emit hilmol m air contaminants as defined by the Bay Area Air Quality Management
Duet? all new materials for inspection. Applicant understands and will comply with
❑Yes oN° all non-point source regulations: . .
1 have readlthe hares mus materiels requirements under IChapter 6.95 of Ne
California Health&Safety Code,Sections 25505,25533 and 8534.1 understand the, .
,if the building does not curently have a,cmm,that d is my mspomibili..to notify the
occupant o e requirements which .t met iTr t suance of a Cenifieste of
Occupancy / Signature of Applicant - Date
:i ,
o u mmi;aegagent Date All roof coverings to be Class,"B"or better