01070111 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19718 VICKSBURG DR A PERFECT CLIMATE 0100,3370111
APPL] UB DATE
"guff"Efft 10570 S DEANZA BLVD 07/232001
PHONE
L (408) 861-9545 SANITARY NO. CONTROL NO.
O z ae ARCHITECT/ENGINEEft: BUILDING PERMIT INFO
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m LICENSED CONTRACTOR'S DECLARATION Job Descripu ❑
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O Z—0 1 hereby affirm thus 1 am licensed under provisions of Chapter 9(commencing A�C ADD ON.
F_u with Section 7")of Division 3 ofthe Business and Professions Code,and my license
u x J Lim nsel fore[an (yep/ (HAVC)
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ANCt ITECT'S DECLAdiATION
C i=O g 1 understood my plans shall be usW as public records /6
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a.S: O Licensed Professional
°' ex OWNER-BUILDER DECLARATION )
F- au 1 hereby affirm than 1 um exempt from the Contractor's License Law for the
following reason.(Section 703 I.S.Business and Professions Code:Any city at county
� O which requires a permit to construct,alter,improve,demolish,or repair any structure
cr3 pro t ts' nca aL q clic ppl cam for such pemtiu file imax!sm¢merm - --
that he sl sedpurs -nttotheproisionsofheContractor.L Law'(Chapter 9 Sq. Ft. 00 , Valuation
(commitment, nhSui' 70(gll f Division 3 orthe Business dP r ,FlrArea
sion,Code) Y 3-1 1 1. •.j ,,,'�:j, ij
or thm he is c:Zms rtherefrom and!the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty
•or not more than Five hundred dollar, ssall. APN Number Occupancy Type
_ o L as owner or the pruriency,(it my employees with wages as their.sole compensation 303 ROUGH MECHANI AL
Bus Business
he work:and me ode:The n most intended d'Or offered rose:alr(sply 1.u. 3 04 — ROUGH ELZ q�QrAkctions'"
Business vet work:ad th Code:The Comminten License Law rose,not apply to al
owner of property Who builds or improves thereon,and who docs such work himself 505 - FINAL ELECTRICAL
or through his own employees.provided that such improvements art not intended or -
'offered for sale.If.howevec the building oo improvement k sold nonan one year of _ . - .._ .-. ..
completion.Be owner-Wilder will have Be burden of proving that he did not Wild or 508_ FINAL MECHANICAL:
— .•, .ny . ..
improve for purpose of sale.). 1
❑I,as owner of the Dscen&mm exclusively d Porcnng with liccmctl contractors;to - -consumer the presto Iappl 7(NS.Business and Professionsilds or The improves
Contractor .
License Law does not apply w mi owner or Property who builds or d Iturc es thereon, l
and who c,Licnsefor-such Pmjttu with.a.<ummemrts7.licensetl pursmnt.m the
. .
_ Contractor's License Law.
- - O 1 can exempt under Sim: � :.8&P C for his reason •M + t I' . , .
Owner Date'
_ WORKER'S COMPENSATION DECLARATION
t Ihereby affirm under Penalty of perjury,one of the following dcclamtions:
❑ 1 have and will mainiain v Cenificae of Consent to self-insure for Worker's
Compensation; m provided for by Section 37W of the Lanor Cede, for the
_ performance or the work for which this permit is issued.,
Cl I have*and will chairman Worker's Compensation Insurance,as required by Section
_ 37W of the'LuMr Code,lin the performance of the work:for which flus permit is
is.- d.MyW k 's Compel anon Insu x and Pol'y n berhrc:
C Pdl' No Q� /•. .' u. I ,,.yr' " a'. C r �•al' r1L 1 '
it
" - : ERTI ICs}ION OF EXEMPf10N FRO A'ORK � \ � " Ik-
_
'inis sen on"need not be completed of the permit is for one hundred dollars
IS 100)or less,I
'\ 1 n fY,thai in fn Pe f dunce f the k for wh h h P lis issued,l - j -� • ,
shalt not employ adyperson ret any manner
an
us to bemuse subjm m fine Wmkcrs -
Crini'matignLawsofCahst Ia.Dam
Applicant
NOTICE TO APPLICA\9If,-arm,making his Consulateof Exemption.you should
z become subject to the Worker s Crnp.natim provisions of the Labor Code.you must
forthwith comply with such p this .hall bdtl
revoked.
z .
.. .-..__. .. _._._ _.. ... ._. - .
W CONSTRUCTION LENDING AGENCY r me
C 7 nt p
Labder's Name,which rF .i-s ss Id Sec.30g7.Ci¢C)yr ��o
In nr Irnnme,at t to Ind g
Len
Addr
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U'O .1 eutily'fnat 1 have read his applicnum tufa so a that the atom inromem-n is
Eat- correct.1 agree to comply with all city'and county ordinances and state laws miming
V
Or •to building construction.and hercny authorize representatives of this city to enter upon
>,,, fel the aMrvc.mentioncd property for Inspection males. ,
F';L (We)agree mm
sose,indcnifyundkee,h:vmlesslhe City of Cupeninoagmiro
tp liabilities,judgments,cons and enpensaa which may in any way mance art said
V z City in'cnnayurnce of hc'pmming nr this pemoit.,,
-" APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT' Issued by: Date
SO' CER Ao ONS. - -7 y'
tum of AppleandContrucmr '•' tc Re-roofs
-, IIAZARDOUS MATERIALS DISCLOSURE. Typo Of ROOF
Willlheapphomit or future building occupant stom or handle hazardous mmedol ._ - - -.. - .-. -... ,.
us defined by the Culaomm,Municipal Code.Chimer 9.12,and the Health and Safety'
'Ctiee.section 25332fa77(.„ ::}. � `,.Masa , e., a '. ..t, �,• ..- ' "::_ s.-' ., . t :,'.' ' L •'
❑Ya• //' ��Nos. _ All roofs.shall be.inspected prior-to_any-roofing material,being.installed._._..-. .
W Il the appl t r_f bails a occupantuseequipmentordeviceswhichIf a roof is installed without first obtaining an inspection;Tagree+to remove
emit hvaNeus air contaminants as defined by the Bay Area Air Quality Management
'DllhillI All new materials for inspection. Applicant understands and will_comply with
we. SA''.`'° I all non-point source regulations._
1 have lead the M1 tab s annals equ re,Bents and rChSpler 6.95 of the
Cdlifomia Health&Safety Cale.Sections 25505.25533 and 25534.l understand that
rue;building does not mrremly have a scmant.hath is my responsibilhy to notify the
occupant of the re,mmism ms which must he met prior to issuarfee of u Cersdii ate of
7 Signature of Applicant.. _ Date
'.' ow re eta
gent All roof coverings to be Class "B” or better
...
OFFICE —