01080065 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0,
22646 SILVER OAK WAY CONDITIONED AIR 01080065
OWNER'S NAME: APPLICATION SUB DATE
FLOOD JOSEPH J AND MARGARITA T 164 B GILMAN AVE 08/14/2001
PHONE:� (408) 374-6311 SANITARY NO. CONTROL NO.
C ee a ARCHITECTAINGINEER: BUILDING PERMIT INFO
µ& BLDG ELECT PLUMB MECH
LJ
y i LICENSED CONTRACTOR'S DECLARATION
v 1 hereby offirm that I am licensed under provisions or Chapter 9l commencing Job Description
',or-P, withS,rion70ATafDivnlnn3nfInBnsmeasand Profession,Coca.and myheart. FURNACE CHANGEOUT, AC ADD ON, ELECTRICAL
In full formand effect.
zu License Class Lac.a
O n Dar Contractor
a
or
fn ARCHITEC"S DECLARATION
1 understand nq plans shall W used as public rcorda
Y
i O O
Licensed Pm(casional
n LL OWNER-exempt
DECLARATION
?; I herby affirm on 1 1. aurin from the Contractor License Low for the
h i 0 %Inchire mason.(Section 7(131.5.Business and Profeaaaons Code:Any caty or counq $6850
F,'L o wh;r t requires a n Pomo re Cnnaw4 mice nt lot such
demmsn,or repair ed structure
a3°_�O Prion L':. also 9 theapplicant the,Contractor's
o rile a Lime,Lwdeamoveramhader9 _ _------
a. _
Inane 1 soapectio mdse provisions of the,the Business
sLam Prilnwlers Cod ) ,sy,• r�Ma ( Valuation
(commencingrthah ,'Ih Sal oman fD Division o the
BumdcvsoMitmI An vi Code) f,,,s?14 t 13 '1"l U,ITU,.'lTl7, �5 '('i�`j,�: '
m that is Is exempt tlorr ap m'and the basis for the iliffic caeth tent to Any violation
:of Section TB]n s any applicant role pemtit subjects Ne applicant to a civil penalty'
:nrnnlmoremanfivenanaredanuarx(SSBm. 301p`PNhN 'RN$ PLUMBIN it,,, ' '" Occupancy Type
°Las owner of dm propcny,or my a,minycea with wages s'their cele cnmpensaion.
will In the xvrk.and the m chare is not intended or olferd-for sale(Sec.9PW.'
'
Bu;aoss'andPoressions Code The Comho l a License Law docs not apply to an 304 - ROUGH EIE24M OPkctions'
through
p,.nyWh buildsormprovesthereon.andv.nockessuchworkhimself
OF 505 - FINAL ELECTRICAL
OF mrgn m:own employees.provided Ince mrc socaimprovements anot intended or.
offered fur sale.If.however,the building or improvement is sold widam rte yea sal" 507 - FINAL PLUMBING I': -- - i r' --'•' --
ao^PNi`;on"uswe.i'blef.w;nn..emewtdenafprn.ingthat nedid nmbaaeor 508 - FINAL MECHANICAL
°Los owner of the pm.7 exclusively contracting MI licensed t trsm - to
construct1M1 project(S Tto a Business o and professions CM )ThC costar's „
p •,w dimprovesth n
1 p ontmcmr(n).licensed Pursuant to the _ ._. _ ._. .___ .. ____. __ _ . . _
Lic<naW da I apply o f n M1 builds
and no mmmela.for soon prnl<e s ,tis
Ch1 tion mos License S
❑Isamexem loader Sea. _ .B&PCfonhis re, on �••J ti'l:y:.i%ali,�� (�
Dan
Owner WORKER'S COMPENSATION DECLARATION
I herby affiml under,penally of jarjoryore of tha following declamtinns:
O 1 have and will maintain a Cenificala of Consent oto self-insure for Workers
Compensation, as provided for by Section 37M of the Labor Cale, for the
peAurmance of the work for which this permit is ivsuW.-
°1 Wit,and will maintain Worker's Compensation I&Mb ce,as acquired by Section
JYBO of the Labor Code,for the pertimm nce of the wotk,fur which this Permit is
" iosacd,My Worker's CI . 1,siaionlmu1.ran2e carrier arid Polary:numbcr in:
..
Cattle, ;' .s, l a l 1 1/..:."hey No - t.
� .A s .. r41 l " f'TSec�'q•T . a S ti. v '1 x.. r - .
is sCERTIFICAUON OF EXEMPTION FROM,WORKERS
COMPENSATION INSURANCE;'' ._.__ ._. .... ... _ ......_ _Ia
ITntt¢ci,inaraed'not hicomplerad tidollar,Perini,is for one hundred dolla �'t,
W 000 less,)
.- _ •, ..., : .: . ..u•.... is _ . __ ___
Ihom i n 2 tie the o in hio_s Pe . t
Com t .tion L any ftc n n any manneras to bcaomc bI a t the Workcn
Cortipeu6i fwsof Calafn. 1Ddc
Applicant .. c ,. .. ... ... .. .. .. .. .. - - __
NOTICE TO APPLICANT:If,ooarmilingthis Cenificaeof Exclnption:you should v
Z hccrime subject hi the W,irkers Compcnmtinn pro<'i ions of the lrbor Cdde.Y�'ilust
Q Q foramoth'mmply with such provisions an this Permit shall be deemed revoked. '
z. "'^CONSTRUCTION LENDING AGENCY - - - - -
a..; 1 beach,c fftrm tnxl than v con.am i l nding agency t th perf..,I.ce - I 1
W'> of lheworkforwbieh draper.),az imued_(Sit .30y)T,Cad.CJ
a.Q Leiatim,Name' - -
QZ leoil tAddrevs' ..
U'Q lc sair,that I have lead this application and ,at duanhe above infmmmion is'.
W I,,, 'wire t l s t comply th all city nor mainly memories a state I rlaong.
Q.U a.Wilding construchoI sand hembi atutionse rarauafvry of flak cityt ter upon
F,W the rabrove-nortioned property for i nspectionpurloses.
L Ise )
U. gern d keep homeless the C ty f C pert nt
V) liabilities.judgments,costs and expenses h h yin any y g ice said
� City in
!!!��///"`"•
CANT Ucnce of the Framing D inu perms[ "
"+ SOURCEREGULTIONS.USANDwICLCOMPLYWITHALL'NON801NT' Issued by: Date
SOURCE REGULATIONS., Y'
Sjntalare.nrAppG<anvcontrndrr ;' .:,' ''.. risme',' Re-roofs
s ,'�HAZARDOUS'MATERIALS DISCLOSURE
wllduceIlicanl or nature boiling remain, t handle n"..mmcrol. Type of Roof, .
ms dai d by the CuKatm'Municipal Coa Chapter 9,12,and the Health and Safety
Cibdi.Section 255320als f VON \s. _ 6,�tv
Oy.11 All roofsshall be.inspected.prior to any.roofing material being.installed. .. _ .._._
Will The applicant or lulure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection; Pagree to remove
Dish he" •amimnts ti's accrued by the Bay'Aro Air Qvallq M...gemem ,
. all new materials for inspection. Applicant understands,and will comply with
rnm cam
°Y °NO al] non--point source regulations:-,,,,
„•. P
1 n' ad the d naanals rtqu ere is and r Chaplin 6.95'of the
Celifomia Heahh&Safety Cade.Sections 25505,255J3 and 25534.I ulWentnrm that
if Ne building does not currently have a shank thein is my respomibility to notify the'!.
o6Ypanl of the regaaretlems which,muv he met
� 1 1-
pit to itme..e ofaCenifi
me of
° " "y 11 ...` I`
" Signature of Applicant Date
owrernr,alnorixaagenr ,' '." , . pate All roof coverings to be Class "B"or'better'
_ _- ". •
t� OFFICE. ... . . ,..