02120067 CITY OF CUPEWI'INO a.- ""^ -- ••+ ',�p.-..
BUILDING DIVISION PERMIT -CONTRACT.OR-INFORMATION:
IORI
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO.
20739 SCOFIELD DR 02120067
OWNERS NAME: 10570 S DEANZA BLVD APPLICATION SUB DATE
PHILLIPS WESLEY J AND CAROL 3 12/16/2002
IONS: MOM 8 11-9545 SANITARY NO. CONTROL NO.
ARCBlTFC`UENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 Lm that
DECLARATION
� I hereby affirm diet I am licensed under provisions of Chapter Y(commencing Job Description
with Sectio 7000)of Division 3.f the(susincss and Professions Cate,and my license is
inmBlnrcc ad y\r/ S NEW FURNACE
Z O"�Z License Clax`5){pyI 1. N
GyF� Date Com
oqZQoZ '�1 - IfIARCI1nTiCTSD .ARATION
OyU 9endcrstand my plans shall be mud as public records
3 LL Licensed I'mlcssumal
A'LLO OWNER-BUILDER exemptDthe Contractor's
0 0 1 hereby reaso ,Sect that 1 nm exempt from Nc C,,dorm o Any Law for the
u�ax❑O followingreason. (mist 9onestr t.alter,improve.
ve.dmoli Code Any city ur county
j4$ which requires a permit re mires the
alcor,i t for such
demolish, file
repair any structure
Fiy that heor tl tensed c.alsoregnithe No,isir so lie Contractors
License aw(Chmmem
55 < (commecing wit purauam r,alhc pmvisionsofthe Cnmmaer'xnd Pro WwlC oditer Sq. Ft. Floor Area $S7�I�f1t100
N€Q tache is(commencingwithScrAfrom and of basisnn3of the
egeBusiness xempt Professions Cede)or
Nn IDI is exempt Ncmfrom and the iasis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of Occupancy e
net more than five hundred dollars($50G).
P YTYP
❑I.as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the swctum is not intended or offered for sale(Sec.704,.Business
and Professions Code:The Commander's License Law does not apply to an owner or 303 — ROUGH 2TACLUons
property who builds or improves thereon,and who does such work himselfor through his
own employees,provided that such imprmcmcros are not intended oroRered for We.If. 304 — ROUGH ELECTRICAL
however.the building or improvement is sold within one year orcompleeon.the owner. SOS — FINAL ELECTRICAL
Wilder will have the burden of proving that he did not Wild or improve for purpose of
sale.). 507 - FINAL PLUMBING
❑ I.us owner ofthepro,my,amexclusively coneactingwith licensedcommittees to 508 - FINAL MECHANICAL
construct the project(Sec.70414,Basin.and Professions(7ode:)The Conmacmes Li-
cense Law does not apply to an owner of pmpany who Wilds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for this reason 1 IV A LE
Owner Dat
WOR K ER'S COMPENSATION DECLARATION
I hereby affirm under penaltyof perjury one of the following declarations: JAN 0 3 2003
❑ I have and will maintain a Cerificam of Consent to self-insure for Wittere Compere
cation,as provided for by Section 3701 of the Labor Code,for the performance of the BUILDING
�UI LD1 NG
work for which Nis permit ie issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section Is7
3710 of the Labor Code,lin the performance of the work for which this permit is issued.
My Werker' Compenaatin Insu n e con r Pn cy mittair anci I
Canic P I' v: lS � V
CERTI AICA SATIONI AN WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the,s tmii is forone hundred dollars(SIO)
nr lcssJ
1 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 become subject o the Workers Compensation
Laws of Caldomia.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
Mcome subject to the Worker's Compensation previsions of the IJMr Cnde,you must
OO fonhwim comply with such provisions or this period shall be deemed mvnked.
z CONSTRUCTION LENDING AGENCY
(+ �N+ I hereby affirm that there is a construction lending agency lot he perfmmanea of
ai the work for which this permit is issued(Sec.3097.Civ.C.)
f31 Q Lender's Name
d Lender's Address
oz
U O 1 cenify that I have read this application and amen that the above information is
P correct.l agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby autherim representatives of this city to enter upon the
above-mcmiencd property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
o-Fi raA liabilities.judgments,costs and expenses which may in any way accrue against said City
CJ in cnnmyucnc of the 6mming of t rmit.APPLICANT NDER.FANDS N WIh1.COMPLY WITH AL}NON-POINT Issued by: Dateha/� V
SOURCE RF ULATIONS. 7 �I/` T
I / V 1 Re-roofs
am fA is
HAZARDOUS MATERIALSDISCLOSURE
or handl Type of Roof
ill the applicant or future Muni huilding occupant stare or handle hazardous mamris
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section pr�s2ss3xar! - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant i k. definedhy
go'"pant um equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit haraNnus air conuminthe Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I have mad Ne harsh u�25533ard
xmquimmenks under Chapmr6 V5 o(NCCaliror-
niaH.Ifl&safety Code.Satio25534.1 undersunJ Nat if Ne Wilding
does not currently have a tenant,Nat it is my..'resibdu notify t occupant of Nc
mquimmenu whichm nem ormissancenfacanirt ver n ./6 Signature of Applicant Dale
r era .,ed agent Dmc All roof coverings to be Class "B"or better