01040001 CITY OF CUPBRTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRER0573 STEVENS CREEK BLVD COMM AIR MECHANIC mFP (R E0 0 0001
OWNER'SNAME: METROPOLITAN LIFE INS 10 2268611 MMIDDLEFIELD GPLICATIONsuhlb4B'02/2001
�PH(INC: (650)261-1500 SANITANY NII. CON'IRIIL NO.
C c Z ARCIII'rECr/ENGINEER; BUILDING P17RNII1INFO
f°O BLDG ELECl' PLUMB f"H
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m�iJ 1.I
S H_ LICENSED CON'I'RAM OR S DECLARATION
p v=O I hereby o inn that l am licensed under provisions of Chapter 9(Commencing
lob DCtiCrIpDO❑
„^� wilbscction]INXO mi.'.m..3oflhelft,ine.,a�addPrnfe..innxCnrL darylicense REPLACEMENT--HVAC UNIT.
G-y ] is in fall farce and cl20 2333`l 5
ren< ❑cense Lie.x
o i Dae Z,-2L_
ARCHI TCr'S DECLARKHON
ELL° I understand my plan..hall he med a.pantie reenede L.
i o O
Licensed Profe......1 /
y�o OWNF:R.BUILDER DECLARAruv 6�0/
I botchy allirm that Inn,exempt farm Ilan Co enactor',Lithane Law tar the
t–= following remain.(scene.9031 S,B,,,Ines,and Professions Gdh:Any city or county
° wan,worim..pm hil to mn.oun,alte,improve,den o i.h,or repair anyswcwre
n5ey Priannill i,wance..1111" ireslbotElicant for such Permit rile a signed!statement
ora he i.licensed national tothe Promhrncofthe Contractor's License Law(Chapar9 Sy. Ft. Floor Area Valu:$idaSOOO
(cconern Bing will,Section 7.X))of Insistm3.1',he Busine,,and Phil L,sinn,Code)
or that he i.aser,Nemo.and the basis for the alleged e.crrdirm.Any Oolmion
of Section]07 15 hY any applleau far u permit 1hI1,1s the;11111 can, ,I a eivll pcuallY
broad mere man fisc hundred dona,.(s500). APN NSM&,4064. 00 Occupancy Type
01,an nwnerof the propcoY,or my employee,with wages m their sale anmpensation,
will do the work,and the structure i,not imendcl or offend for she(Sec.7014,
Bit„nes,and Professions Code:the Co ema,he's License law doe,ran apply to an 301 — R�IL9&F4d ItrLPSN453PNG
overt,r of property Who builds or improves themen,and who dues such work himself
g 303 — ROUGH MECHANICAL,
or eyed h his nwr moves,t lemilded eel such Werem I,a Id me ern.intended or
offered fur sale.If,moves,the M,ndmg o,unpmscment I,-Id within nee year of
ea„pmtior,,n,e owm�nnaime,w'un,n�e J,.ham...nfpm�ies mal be a;a not nwm or .. 304 '— ROUGH ELECTRICAL f
m,pmve forvurTaw of,ale.).
505 — FINAL ELECTRICAL
❑LasoNher^ryas`atope.7044. swish„ydProleamsCodifli encdeCnemt,ln 507 — FINAL PLUMBING
,nar,rn m. t Iia.ni44,mt.ine.,and Prore,.mn.cwea The commeu,r•s
Lwan..Law die,an apply to no ownernr pmpcdy wish hunlds m'immosel more".
and N'no eomraas for such pmjecb with a comractorf9 licensed pursuant to the 508 FINAL MECHANICAL
Coacn'to"Licerue Law.
01 am exrntpt under Sec. .B k 1'C for thin reason '
Owner Date
W ORK17R'S COMI-ENSXHON DECLARATION
• I herchy affirm under penalty of icTury one of the following declarminne
u l hove'vnA will n amain a Crnifeme of Comm to w1binsare for Worker's
Campcnmliun, ;, provided ba by Section 3700 of lie Late... Core, for the
fe rfunnanw o1 the work for which this pcnont is I...ad.
❑1 hoe and N'ill mainwin Worker's Conyumlaion Insurance,as required by Section
3711)of The Lubar Calc,for the PerGnnumce of the work for which this permit is
iswW.Aly Workers coal .tio_n 11,�w,I C eerier and Policy m other are.
Carrier: ertpsi— L Policy Nn.:
CEKI IFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sea, need nm he.........lead if me permit i,throne hundred dollar, -
ISI00)in,le".)
I cenil'v that in IM perlarmance of the wok or which this permit is issued,1
shall nal employ arty Person In any manner w,a,to become subject to the WorAns'
Condw ,adnn Lnw,of C,,Idbonna.Dote -
Applican
NOIl Cli9OAPPI.ICANm If,asci ma king ibis cerifrae of Exemption,you should _
become.ablect to the worker',Cmrtpen bion provisions(it(lie L
e ,bor Code.you must
Q tormwim comply N'im arch ro—ion,n, his l,v.if.hall be deemed revoked. '
FtiCONSTRUCTION LENDING AGENCY
> I hereby alfr,n flat mere 11 a cne,lnmtim,IhnJimg agency for tha Pedinnnaee
of the work let which Inns Pmm,is,...ad(Sec.30X97,Civ,C.)
1 Q lander',NI w
z bambh',Address
V I ceeif,that I hash read his uppliwoom and stmt Ihat anis above inh.nnmion is
Fs. t-t
correct.I agree Lir comply with all city and county ordinances and state law,relating
O (,) mFundins eon I...ii,) ar,I twoby uoduniac prewcnlaives of mi,any Lir enter urym
the oMna-tis mpeny rim inspcaia-purpose..
E” y ngmc urn indemnity aced kcup bnnuless lie City of Cnpcnimr against
As.
VJ Iia a.,juJgn co .and ea w.,which tiny in any way acwc against and
f..) z .tfy cis uc' I't gr:v ' dmi,p.nnit. —�
SOUR HE
TA' )WILLCOMPLYWITHALL oNPOINT Issued by: K=< Date —
%f'- 0
,�nrnhp n✓ , metro Dale Re-roofs '
HA'r RUOUS is 'H b",'DISC'USURE
Will theappliOnito,future budding occupant time handle hvuNommatedal Type of Roof .
r,defined by the Cup.rl.to Mamici ed Code,ClnPe,9.12,and the Hewed iced Steel,
CMe,Section 25532(u)7
ElYes rho All roofs shall be inspected prior to any roofing material being installed.
Wlllme apptwanlor future bn'ddinsrice.porn use egaipmemsrr device.which If a roof is installed without first obtaining an inspection, I agree to remove
mnnl hvallou,air eantmninanb un Adi ed by the Ray Arca Air Quality Mwagemenl
.
Thi...;0? all new materials for inspection. Applicant understands and will comply with
0 ye, "° all non-point source regulations.
I base
nal lie h ,ndk mmerial.mo ni ode,Chapter 6.95 of the
CaId mi CITB'N my Care.Sections 25505,2 5533 and 25534.1 understood that
irthe ddingd}u- I am
curly havonenun,,thait is my resrym,ibilitymnmify the
pans r I C re ydS t nl, It roust be mot pdm m nm
issuance of a C. .ae of
reupa
Signature of Applicant Date
Ownara mm�a, .n ng. Dam
roof coverings to be Class `Br' or better
OFFICE