00080080CITY OF CUPEWFINO
BUILDING DIVISION PERMIT
MAREM
LICENSED CONTRACTOR'S DECLARATION
affirm that I an licensed under provision of Chap
ARCHTTECPS DECCARATION
I undmtad my plans Nall W used n public recmda
Liccmd professional
OWNER -BUILDER DECLARATION
1 hereby a1fim1 that 1 ase exempt from Ne Comnemh License Law for the
following lesson. (Suction 7031.5. Business and Proesuom Code: Any city or counq
wMob repui rs a permit 0 ecnmics alta, improve, demolish. in mpac MY asmcturt
prim to its issuann, also rex uirus the applicsns for such permit an file asignd aluminum
Nat he is licensed ponwm to the provision of the Contfector's License Law (Chapter 9
(commencing with Section ](WI of Division 3 oftW Businea ad Holessiau Cde) At
WI he is cwmpr Nnef ton ad the basis for Ort allcgd ewmptiom. Any violation of
Section 7031.5 by any applicant fora Pemba subjects the applicant to • civil penalty of
no more then rive handled dollera ($503)
I, u Dane,' of the proPanY. m my employs. with wages n thcirwl<campewdon,
will do the work, and the structure is not inandd moRemd fm aale(Sec. 7064, Bniners
and Profession Code: The Contractori License law does nal apply on an me' a
propcny who build, or improves thcremt, and who docs such work himself m through
his own employ., pmvrd than such improvement. are nal ideaded m (Reled for
Wo. If, however Ne building or improvement is sold within one year mcompletion, den
owrcr-W rider will new thin hdden of proving down W did nal Wild or inpwva for pur-
pose of Baia.).
1, in ower of ds property, am exclusively contracting with licensed conaacron Io
construct the projcet (S.. IDH, Rusin. and Poland.. Code:) TW Contncrds Li-
corne law doe, da apply to an owner of property who builds or impmvea lheretn, and
who ...is fm sueh pmjecu with aconta mux) lianacd pursuant An the Coaoecmla
License law.
l em exemptunder s". . B & P C fm class .ern
Owner Da¢
WORKER'S COMPENSATION DECLARATION
1 and
waRrm mala penalty of perjoty one of the followingwomme. eclipsed. I have end will for b in a tion icate37M of be sexam Labor Code.
the Workela Compw-
ution, as provided for by Section 3]W of be Labor Codc. fm the pelfomurce of the
which Nis permit is issued.
eve and will um.for in do C.film w Insurance, n his per by Section
l7W of IW Ia�AWr Code, lorgNc pertormemc of Ne walk fm whicM1 this Rn^u u in
MYWCam ,l pro s T.' A 1Y npol
policy
No, a d
CERTIFlCATE F EXEMPTIO-itN FROF"ImlM WORKERS'
COMPENSATION INSURANCE
(This wclion need not bat compled ifdte permit is (Drone hundred dollen ($]W)
or Icxs.)
toy a., that re in performanceof the work for which Nis temutisaWColshill
nal employ any person in any runner w n m become xubject in IW Worsen' Compen-
ution Iowa of California. Dad
Applicant
NOTICE TO APPLICANT. If, after making this Cenificate of Exemption, you should
hewn , subject m IW Werke/s Compenation provisions of Ne lino' Cde, you most
forthwith comply with such provision or this pe rat shell W deemed revokW.
CONSTRUCTION LENDING AGENCY
I Wraby effort den Nen is a conawcimd leer ing agency for In, performance of
Out work for which this permit is inued (Sec. 3097. Civ. C.)
Lcndmex Name
Lender's Addle.
I ct dfy NL I have Lead 1111, tlppinatiml and,nte that dim aMVe InfmnnOnn Is
conal. I agree to rnmply with ell city and county mdirunc l ad Fuse laws relating..
building coomboc on, and hereby adhorioe repnscmutives of this city to Omer upon the
above-mcmiml propel for inspection purpose.
(We) agree to save, indemnify and kcal, harmless the City of Cupertino agalmt
uabilidw.judgntenu, cru and ..,mer, which may in any way aeema.gam,, said City
in con.vol.cnce of the granting Of this permiv I___I_
US MATERIALS DISCLOSURE T
Will Ilcantmfu Wilding omupanl atom or handle hamdoux material
u def and by be Cupertino Municipal Cde. Chapter' 9.12, dd IW H alN and Safety
Cde, Suction "532(.)7
❑Yes ❑No
Will Ne applicant or future Wilding meeupant man, equipment or devices which
,mil havtdom it conuminants es defined by the Be, Ana Ail Quality Marragemrm
District?
❑Yas ON.
I ve mad thehavtit ^^pBto As lcquimd
tenu oder Chapter 695 of the Cali-
fs�u t�lth & SafeW Code. SecIMu "505, "533 Ord 25534.1 mduJland eget if the
RF_SIDENTIAL HEATING AND A/q IN000800
NIC C(INTROL#
65 CRISTICH I_N ID 08/11/2000
BOLDING PERMIT INFO
4083774073
Job Description
REPLACE FURNACE AND
R/C
4
�/? a...../'
Area
204 —
UNDERFLOOR FRAME
301. —
ROUGH
PLUMBING
303 —
ROUGH
MECHANICAL
304 —
ROUGH
ELECTRICAL_
505
— FINAL
ELECTRICAL
507
— FINAL
PLUMBING
508
— FINAL
MECHANICAL
514
— FINAL_
PUBLIC WORKS
Re -roofs
Type of Roof
$1
All roofs shall be inspected prior to any roofing, material being
installed. If a roof is Installed without first obtaining an inspection
I aggree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
OFFICE