01080105 CI TY
NG DIVISION PERMIT
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22636 SILVER OAK WY CONDITIONED AIR 01080105
OWNER'S NAME: APPLICATION SUB DATE
JEFF PAGE 164 B GILMAN AVE 08/21/2001
/ PHONE: (408) 374-6311 SANITARY NO. CONTROL NO.
1.
O s z ARCHITECTIENGINEER: BUILDING PERMIT INFO
K w O BLDG ELECT PLUMB MECH
aLl L_I I_J -I
v= LICENSED CONTRACTOR'S DECLARATION
I briefly oRnn that I am licensed under provisions of Chapter 9(commencing
Job Description
'„�,°„ will,Srnian7000torDi,ikina3afilm BmintssandProfevoinoCodgaadmyIntense FURNACE CHANGEOUT, AC ADD ON ELECTRICAL
is in full fame aad erteet.
i z a Licc se Clea Lic.a
O a D Dae Conimaor
i 3 u.y ARCHITECT'S DECLARATION
1 ondauand my plana shall be mad us public records
or
i or
i etC O Lironsed Pralessional
o pre, OWNER-BUILDER DECLARATION
1 hereby othrm,bnm exempt 1 nexempt from the Commencer Liceom law for the
z< fallowing reason.(Seen.7031.5.Basins,aad Profuuions Code:Any city or choly $4800
❑ which myuires o permit m consauct,alcor, ve,r,improdemolish,or repair any suuaure
thn hq efc nsed p' .;hrmth Pro mof the Conuanora to
Licenselaw(Chaptcr9 pp�� gg,,�'�7 p�qa 1 Valuation
(caricaturing with Satm700)of0',isinn3nfthe BuSutcis
timall'rofesstom Cale)
or that fie is exempt thertfrom'ond the basis for the alleged eketa'pthm.Any violation t
of Section 7031:5 by any applicant for a Pcmtit subjects the applicant to a civil Penalty- jy,
of not mom than five hundred dollars(55001. 30-..p&NNF(�tap{5 GH MECHANIAL•"'' '' Occupancy Type
O1,as owner of,hc property,or my employee with wags m their sole compensation. _
will+do'Ihm
c work,and rhe ntacre is fun imcodcd or offered far.sale(sec.70 1,
Business and Professions Code:The Comracmrs License law does not apply to to 505 - FINAL EEylp`irFMG *mons 1.
owner of prnperty Who builds or improves thereon,and who docs such work himself
or through his own employees.pmrc vided that such improvements anot intended or . ......
5 0 8 - FINAL MECHANICAL _
-,offered for sale.IL however.the building Lir improvement is sold within time year o/ _ -
mnfilaion,the owner-builder will have the Women of proving that he did not build or
improve or Prefixes of sale.l.
ownr of the property am exclusively Contracting with Bernsed emulanurs m { -P111 i+
cnnswet the pre cet ISec.7144.Be,inxs ad Pmfeosians Corry The Cnmmrmr's
License Ww does not apply to an owner of propcny who builds or improves Braman. FIN q
" .,.and wha.rontmws for smin,ojects with a contmcmrts)Ilcervol pursuvm.n.the..
%y Own r.�•,�'' � Dvtd i i sell .._ .. ..----'-- f•. ,� ,.E --._... --'----- --.-- -
nttactors License
law D
clam exempt ander secs' t ,a&Pe ronnsteas :ni
OCT 1 2001
WORKER'S COMPENSATION DECLARATION
t, 1 hereby vflitm under penally of perjury one of the following declamti...
p13 1 hiot'sed'wdl mviamm it Cenificaie of Consent,la self_imme far Workers BUILDING
!�•y Compensation, as provided for by Section 3700 of time labor Code. few the
perrormana nnWa w,ax ror wmrn cola ptnait is issued.
❑I have and will mainwin Workcr'.i Compensation Imuran(,as required by Section
_- 3700 of,tie Lebo,Code,for
he.pe;forni of the worklfar which this pi is
ioneu.M Worker's Compcnviio lnsmne cairicr and Policy numb2ram: -
'6innA t t P t a j\'Policy No' 'i .. t rQ� rY C}I y V 1ih
1(.-i CCERTF-7(CATION OF EXEMPTION FROM.WORKGRSi e- - v- `
COMPENSATION INSURANCE" "" t,
(b1 , sedioti imed nd be csimPle¢d if @c permit is for time hundred dollars
00 W)or lcole sa '
�� I rirytht'iniheperf...ree of thework for Which'his ah tis i.cmed,l , ,,I : � t, 'i�.t; �� •'
shall not employ w'y' crson in any and er,so as to become subject w the
Q -
- V w
krra
CmPcsmioLows of CahniaDc
Applicant C. 0.o
NOTCETOAPPLICANTIf fmakingth Certificate
ofCxepti yew should
z subornLirtheWokersC)nmernnpmern. fJe, minor
fon HwirBromply with suchpmvior ,or
'
this permit shall be deemed revoked.
Z2 ._ ..__._ _... .. -.. . _ - --
'In 'CONSTRUCTION LENDING AGENCY "• ll..- .:.Di"t^. °i•'"1'hircAy uffnn thm,bete iry cnnnmction Ictiding agency far the performance "
r
-7
of the Work for which this pirand is issued(.Sec J(NZC¢C.) " „ ', „
Q -Eeoder•s Name' - - - - -
�;I:Z I<nder's Address _ 1,•';.,.� ..:
U:0 1 certify that 1 h read thisapplication and state that theabo f rmafon is •r
(D t~. cone t 1 gree to mply he II city d myordinancesrattd t t 1 mining
Q U the ids -a r d n oy byecschoolsp t t es fth city to mw poll
bythe bo a e) r d save.pony fo Pct W To ;
(s,odgrc'tsidamnifyand keep harmlessthe Gp of Cupertinoagainst
rn , liabilities,judgments,costs endmr expenses which may in any way ucrve against said
U".'Z Airy in cANT UNDERSTANDS
R the NDS A D Inls permit. '
SOURCEREGULTIONS.DSANDWILLCOMFLYN'ITH'ALLNON-FOINT�" ISSUedb Dale
_ SOURCE REGULATIONS.'„' �' ., ,r• y•
Signature ofApplicam/Contmemr'` ; ' ' ' t L .Dae Re-roofs
HAZIRDOUSMAToal Cha DISCIASURE ` •Allroofs shall be inspected., riorx-, an• r
♦. cantor faro bold gocupa r tore w bag recitationsntaenal Type of Roof
• Cupertino.Muni iP I Cak Chapter 9 12 a J the Health and safety f r -•.v -
e app
as def di, the ` ;'t I
Code Ser n2551:(a) il;f .'I rll ' r5;, 4
w P" ,.,',Tal '1' p y, oofing material being installed._.._
Will the applicant`or future building occupant,use cgo p t or device.which If a roof is insialle'd'witlmut first obtaining an inspecti6n;41 agreeao're hove
emit haz'allous air coatamibenb as defined by the Bay Area Air Quality Management
Di.iriee I all new materials for inspection. Applicant understands and will comply with
❑Y. - : - ❑Na ` all no
n- oinf source ie a kionS:
,ph.e mad the h anrd smuariali rey rerncn¢.und r Chapter'6.95 of the
California Heahh&Safety Code.Sections 23503:2533]ark 255?J.l undmtand thin _ _ ..
,I he building does not cuncmly have v rcnvm;that it is my responsibility to nmify ibe ,�i•;
co m p of th r gmrc i h h mon be i,pri no issuanE Yv Cmifimm of
>• ! Oce pancy
„ .. r'1 � Signature of Applicant _ ._ . Date _
t.
ow,a�r p.ayth�na<d agent,:;', Dared.... All roof coverings to be Class "Brr or better '
_. .
OFFICE