02050090 CI Bun of c DPESSIiONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19061 TILSON AVE CONDITIONED AIR 02050090
� A IYTErPAVASSOLI 164 B GILMAN AVE ACP C' )yf�72nF2
PHONE: (408) 374-6311 SANITARY.NO. CONTROL NO.
Q00 ARCHITECTIENCHNEER: - BUILDING PERMIT INFO
w- BLDG ELECT PLUMB MFCH
I8 i
LICENSED COMRACnOR'S DECLARATION ��h Qe
j�yo `' :,;'.I¢ctebya(red Division
3.f,hudunderp dpronsofChCast d license
FURNACE CHANGEOU'P_1 77 p iOn
C; .wish Sehi' ) j of Division 3 of the Busi and Pmfe ions Cwle,and my liccnu
is in NBC
ff �cJSy
9 rc e 6 License CIaeC C N
:
:0W O Cnnouc
r S p G R ITECT'5 DECL An
3 I undentand my plans shall be. d ax pubic mc ids/t(2 k$SG=
342
)_a O O Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm the 1 amI.S.exempt from the C stone o License Law for the $6675
following mess a wood to
"1(131. Business and ss.demo]
eo]i Code:Any city or county
Y F o which require v e.also reconnected,Ater.improve,demolish,or repair any structure
aa. c� prnt reinrequireslli pplx If hrarnnolle.av gndl statement - on - -
..noon... ....
it,
Lircrsc
that lie sf al tilt-tri provisions n nh c IusinessndProawonsCorr9 ,. 3' O�OI9�e3r®@a ); : ,-•;,, Valuation
(cam seeing awith Section 10M1 dD vii 3 f theBusiness and imi.Any vi Code) , ,
w that be Is exempt,hcrtfmm and the heels for the alleged eaunpliod.Any violation '- -'
of Section than v any hundred
-am 6r a permit subjecu the vpplicam to a rnil penaly
of not mere man five n.nartd a.nart(ss0o). 301ARN 1QQttISBH PLUMBIN I it. .' Occupancy Type
❑Las.wner. the p,nam..rmyemployees with v.,,n,thei,:.lecnmpenswion. 303 - ROUGH MECHANI AL
will dome work,and the structure is nm intended or Offered for sale(Sec:7044, 3 04 - ROUGH ET�y T
Ousincas and Professions Code:TM1n Contractor's License Law does not apply to an ''ifC lAfe ctions:
.wee
r of properly who builds or impmven thereon,and who d„et such work himself 505 - FINAL ELE TRI CAL
.r through his own employees.pmvlded that such improvements arc not intended Or .... .. . . . ....._n oon . ._._.. ._. . .
',offered for sale.If,h..,,c,the building br ithpr.veemm is sold within ane year of - - -- -507- FINAL 'PLUMBING'
completion,the owner-builder will have the burden of proving that he did not build or 508 - FINAL MECHANICAL
improve for purpose of sale.).
._ . .. .noon
construct
Laxowner ofthe P(Sec.7 am exclusivelycomrofessi withlicensed Contractor
oanorsrx .. •'
kens et the preset(Sec.]loan Business and Professions Coxills Or Theimproves
ves them n, .,
License Law tract not ripply loan owner of property who halide se improves thto Un
Co twhgcnmmcts Ina such projects with.¢contractor(s)licensed Pursuant 1.the ..._... ..._ . .. ..._ ..._ .....__._. ...__.._......... .._noon ..... _ _._.__. . .._
Col am ex
s License Law; ,
”' Y. ❑I am exempt under Scc.' .B&P C for reason
. ,� � � ... � . . . t .v._.
. Owriei::e:t.r ! •Dae
WORKER'S COMPENSATION DECLARATION ��p g p �Ca®�ew, A LFSO
•.•. .•1 hereby affmm under Penalty of perjury one of the following declarations: V 6„', G ,gyp I�
o I hate and will ',Amnio .Cenifcate of 6nteint lo self-in...c for Worker's MAY 3 1 2002 JUN 0 3 2002
Compensation provided for by section 3700 of the Labor Code. for the
perf.m,ana.ithe work for wmcn this permit is issued.
01haxeandwdlmaima.wtrke;sC.m;n t;.nint. nee,aa �.imdb Sanson BUILDING BUILDING
3]00 f theLabor Code par tire performs of the work o
for which this permit
issu❑My Worker,Citpe tau�n ins.m eyd P.1 cy tuber art
Vic
I „Clz TIFICATION OF EXP. 1'TION FROM WORKFHS
INSU
COMPLNSAIION ,I[A1VCIja' e aglf�
✓✓44�t 117 I .... -. .. _.._ .,.. _. -..
(Das sed ori need nw be compiled f the perms s or one hundred dolls
(5100)or lcssJ
. I certify"nom
the a inna,tarm or r walk roc w me this peood is
shhll'am employ any person in any manners.a to become mbject to the Workers' ” "
Compensation Laws of California Dam
APPIa ni .....__.
.NOTICETO APPLICANT If fnon"
k gIM1'.C n m t ft pt Yash telt
0 b.Z`c subjaet 1.the Worker s Compeer Ion pro 's ons Of me Lahnr Code you must
(.'his,b comply with such pmvisiont or this permit shall be deemed revoked.
z r .. ---EN
noon . .. noon.
.moi " CONSTRUCTION LENDING AGENCYof,
,I hereby affirm that turn,is a construction lending agency for the performance
Tia r4 Lndus me. C) ,'
Q
he ismic
Name
for
which thispet is issued(Site'3
rm091 Cis....
V'� yhi s t ,i thvt l tinvemad this ppiic t nd inue,lub,herithaveninkmornicia,s -
W [r cor er,I agree to comply with all any andtrc,ordinances and state laws reining
0 V to building construction,and hereby authorize rep umatives of this city to enter upon
the above-mentioned property for inspection puryous.
(We)agree m s.m.indemnify and keep harmless the City of Cupertino against �[ /
tq 'liabilities,judgments.costs and expenus which may in any way¢verve against said
C.7,1 z City in consequence of the granting ordt"permit.
^ APPLICANT UNDERSTANDS ND WILL COMPLY WRH2 0 INT ISSned by:
Date
SOUR NT UN J O
ignature of Appli ilbCaffloarlm
HAZARDOUS MATERIALS DISCLOSURE" Re-roofs
❑Y. l No ng occupantstomorh Jleharaidommaterial Type of Roof .. . . . n -_ :' .
Cad Ch pte 9 12.and th Helm and 5 fey -
_ Will the applicant future Wilding
. : asst d io the Cupero32001 M ,p l
Code Section 255121 1 , t. ,.
f-4 At roofs shall be inspected prior to anyroofing. being.instalIed
,- �, , noon.
wli ro epi� I f t building e t q.p eel d '„nen If a roof is installed without first obtaining an inspection, I agree.to remove
km t hazard co t ed t o ddyee by,he Be,A a Air Quality Management Di t t v all new materials for inspection. Applicant understands and will comply_with
(r1{ -\ _' t ❑Yea. 0 all non-point source regulations, .
R ;1� 1 have',cad.the hecardousmaterials requimmen¢under Chapter 695 of de
California Healtn&Safety Code,Sections 25505,25533 and 25534.1 understand that
ifthbuilding does notcurrently he ateant thatit- myrtp 'bitty to notify the
'd p t of therequirementsmost be met priororissuance f nifc sof
Dep y SS _ ignature of Applicant Date
.r aathnt;rw ant D All roof coverings to be Class "B"or better
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.OFFICE "