05040124 CITY OF CUPERTINO �ypa♦�nFr�-s�"gyp yk�"/s»�s"' yl
BUILDING DIVISION PER MIT 'aC0M_ 1.L RI i?EL"IRMATUO
BUILDINO ADDRESS: PERMIT NO.
MARSHALL' S HEATING & COOLING 05040124
OWNER'S NAME: PERMITISSUEDATE
NE: SANTARYN ftMOL NO,
ARCHITBC IENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
B;G LICENSED CONTRACIOR'SDECLARATION
EI hereby rt0rm that I am licensed under provision,of Chapter 9(commencing Job Description
a W with Salton in cffe Dlvltlon3rf the Business aM Profeuinns Code.And!mylicense is ��
G in full force an effett
j
her
o C Lk.I S �-s GAS LI C OKTOP
Dale TS DECLARATION ARCHITECTS DECLARATION
'y9 I understand my plans,hall he used As public records .//�'f
0 Licensed Professional �a 2005
OWNER-BUILDER DECLARATION
OX I hereby&film IMI I am exempt form the Contract&&License Law far the'
Mo following mason.(Section 7031.5.Business and Professions Code:Any City or county
$ which myulre,a permit to convect,also,improve,demnliah,car repair any structure RI III nINa
r prlormis isauanee,elm mqulms the applicant fortuchpermilm Nes signed suument
bi Ihathe lalicemed punuanlmlM pmvitions.fLWCmumtm'r License luw(Chaper9 q. [. r ValUatlO
(commencinSwith Section 7000)of Divitlon 3 of0e Businessland Prokssinu Cnde)m
Nat W is exempt therefrom and this basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for,permit subjects Is,applicant to a civil penally of 3�8��OO�f 0 0 Occupancy Type
non mom Nm five hundred dollen($500).
❑I,As ownerofthe propeny,or myemployea with wagesulbelrmleeompenntion,
will do thewoh,and the mumute Is not Intended oroffered fortale(Sec.7011.Business
and Pmlesslo s Code:The Comn.mrs Lkmue Law dos ani apply m an owner of Required Inspections
property who builds m Improves Ihemon,and who dauah work himself or through his
own employees,pmvlded that such Improvements,Are not Intended chaffered forsale.If.
however,the building or Improvement Is mid within one year of ComPlelion.the owner.
builder will have the hmden of proving that As did not build or improve for purpose of
sale.).
❑I,as owner of the Property,am exclusively conuaminS with licensed contra sou to
conswct the project(Sec.7044,Business and Pretensions Code:)The Contractor,LI-
Cense Law dao not apply in an owner of property who build,or Improve,thereon,and
who conumm for such projects with a contncm!(s)licensed pursuant An the Conemers
License Law.
0 1 am exempt under Sea ,B is P C for mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affnm under penalty of parlor,oro of she following declarations:
I have and will maintain•Certificate of Consent to selGimum ren WorkersCompen-
IC137.'
on,u provided for by Section 37M of the labor Code.for Ne performance of the
rk for which this permit Is Issued.
1 have and will maintain Worker,Compensation Insurance,u rcquimd by Section
0 of thou labor Code,for the perf omaae of the work for which tall permit is Issued.
Workers Compensation Insurance[artierend Poliq mantlerC��rertler.6710r �.J 7_t x PolicyNo.:1'1 :
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(!his seectla need not ha compk ted tribe permit is resume hundred dollars(SIM)
or less.)
I cenify that in the performance of the work for which this Permit is load,I shall not -
employ any Person in my manner an As to become subject to the Workerr Compensation
Law,of California.Date
Applicant
NOTICE TO APPUCANC Jr.after making this Certificate of Exemption,you should
become subject in fie Worker's Compensation provisions of the Libor Code.you must
,J O forthwith comply with such provisions or Ibis permit shall be doomed rooked.
q CONSTRUCTION LENDING AGENCY
[—, Iherchyaffum that there is a couiruclion lending Agency for lM performance or
a the work for which this permit is Issued(Sec.3M.Civ.C.)
�W Q lender's Name
z Lenders Addrms
U O 1 cenify that 1 have read this pplication and sou that the above Infomallun h
W
comet.1 agree to comply with all city and county ordinances and aide lawn matins An
O V building construction,and hamby morodm mpresenmives of this city to enter upon the
W Nem-memkned property for impaction purposes.
6. (We)agree,to save,Indemnify and kap humleu tis City of Cupertino against
fA Ilabllitler,Judgmenu,cmu and expenses which may in my waysccruc Against said City
<)7
1....sequence of the Snoring of this permit.
�7 AP ANT UNDERSTANDS AND WILL COMPLY ITH All.NON-POINT Issued by: Date
S a e uLATfekq. �/_11—ps Re-roofs
So rcrfApplicsonom
use
HAZARDOUS MATERIALS DISCLOSURE tor Dau Type of Roof
Will the applicant m fmum building occupant or handle huudout material
u defined by the Cupertino Municipal Code,Chapter 9.11 and the Health and Safety
Cade,Soni..25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya Na
W111 the applicant or furore building occupant use equipment or Jcvlas which If a roof is installed without first obtaining an inspection,I agree to remove
It hu.adnus ars amaminsnu as defined by the Bay Arta Air Walley Management all new materials for inspection.
elllet?
❑Yes
I have mad tie to andnm makrisu requirements under Chapter 6.95 or the Califor.
nia Health&SafetyCmk,Sections 25MS.25533 and 35534.1 understand that lflhe Wilding
does at currently have a much,that It 4 my mapomlMllly m atify the uxupant or the
m emu nth met wtuamaoanf ream of Occupancy. Signature of Applicant Date
rL �/— a 5 All roof coverings to be Class"B"or better
ftpimr-mthmoed agent Dee