03030104 CI TY OFCUPERTINO - 7"k'tY'°"z« .'^,�,k�+�.I,'��m"`•r' Y'y� ^yttg�,g
BUILDING DIVISION PERMIT }mayCOs•`ITRA„y�'*,T�U',R�I1�,�,�O4• i j�'�1
aau1LDINGADDRESs: CONDITIONED AIR PERMITNO.
OWNER'S NAME: 1701 LITTLE ORCHARD ST PeRn1ITLg
NE: (408) 291-2220 SANITARY 0. C NTROL NO.
ARCHIT117VENGIN TIER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
1Z1 hnth'affirmThal 1 em licensed under pmvWom of Chapur 9(commencing Job Description
s< with Section 700g)ef Divlalon 0 ofdu Business and Professlnm Coda,and my license is
- in full fora and effect. r j�,7 Fw'w
,gz Limne,Clea. Lit.• REPLACE FURNACE h A
Dau CONT
ARCHITECTSCminDECLARATION
ION ryry
l I understand my planaused W ed u public mcotls
J
- UN 12 Z003
-Wp5 Loomed Pnlinishul
.5 OWNER-BUILDER DECLARATION Loomed
1 Wmhy aean ffirm that 1 em exempt from the Contractor's License Law for the BUILDING
o O following m (Smtlon 7031.5,Business and Professions Cc&:Any city or county
3 g which requires s Permit to mrswct,slut.Improve,demolish.or repair any suunure
t priminitsissuance,alsomqulmttheapplicantforsuchpermittofileasignedstatemenl Sq.Ft. Floor Area '7$2%lyg titin
< than W it licensed pumuant N the provisions of the Contractor's Licenselaw(Charter9
(commencing with Section 7000)of Division 7 of the Business and Profeulons Code)or
"x ..
that he is exempt Nemfmm,and the basis for the alleged uempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects the sppllcat Ir s civil penalty of r,A�jjTIgT�ierO 0 Occupancy Type
not mom Nan five hundred dolls.(5500). 3
❑I,as owner of the property,or my employees with wages as dulnole compenaellon, p
yyg
will do the work and Bhermome ,is not hiuMed m n
offered foale(See.70M,Business - 301 - - ROUGH iR RINFections
and Pcefessloa Cock:The Coussur's Liaems,Law does not apply u to owner of
property who Wildsmimprovea Bourton,and who doesauchwmit hlmselfor through his 303 - ROUGH ML�'CHANICAL -
ownemployees,provided that such Improvements amnotinuMedor offered for sale.If, 304 - ROUGH ELECTRICAL
however Ne building or impmvereenl Is sold within oa year,or completion,Ne..
bullduwiOMvethehome.of proving thathedid out Wild.Initiation,for purpose.1 505 - FINAL ELECTRICAL
ale.).
❑1.a owner of the property,am exclusively mnuating with licensed conuacton m 5 0 7 - FINAL PLUMBING
counter the project(Sec.7044.Buineu and Professions Code:)The Conuaur's LI• 508 - FINAL MECHANICAL
cense law don not apply to an owner of property who Wilds or improves thereon,and
who contracts far such projects with a conuacmr(a)licensed pursuant to the Cim icimS
License Law.
❑l son exempt under Sec, ,B@PCfolhismaan
Owner Dau
WORKER'SCOMPENSATIONDECLARATION
I hemby afllrm under Penally of perjury one Of tits following declarations.
I have and will maintain a Certificate of Cameral.self-foam for Warker't Compen- -
ution,as provided for by Section 7700 of du Labor Cade.fm the performance of the
vforwork hich this perm i is Issued.
ad will maintain Woker's Compensation Insurance•as inquired by Section
37W of the labor Cade,for the performance of the wok for which this permit is Wood.
My Worker's Compmalm launncecarie ad Paliu un O�
Cartier.. Q. Policy No.: O
CER FICATE OFEKEMPOON FROM WORKERS'
COMPENSATION INSURANCE
(This action need not becompleted if the permit B forme hundmddollars($100) _
or lea.)
1 coolly that in the performance of the work for which this permit Is Issued,I shall not --- _.�_ ... .... _ ._.__�_..,..�...__,.._ -
employ any person in any manners as to become subjmLto the Workcn Compenastlan
Laws ofcallfornta m
AppHeant A 4.aM -
NOTICE TO APALICANT:If.Ifet,making this Cenhicau of Exemption,ynu should
become abject to the Worker's Compensation previsions of the Labor Code,you must
7Z forthwith comply with such pmvlsimts of this permit hill be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I Witty of0rm Bun Nem it aconswction lending agency for Ota Minfor m mix,of -
x7 the wish for which this permit it hound(Sec.5097,Co.C.) -
y Q Lender's Name
Z lander Atldmu
J Q 1 cenify that 1 have mad this application sod sou that Ne above Infomttfn Is
U corona 1 agree to comply with all city and county res omtanttt and sou laws r upon t he
e
Qt, building herohyectionpurpos sensitives of this city to enter upon the
?+a above-mcntmned Properly for inspection an keep hots
(We)agree to ave,indemnify and keep humins the City of Cupertino idagalint
City I �y
U liabilities,
quencjudgments,the craning axpeaeswhich mryln anyway strut against City {�
J In APPLICANTtUNDERSTANDSof Ihis AND WILL COMPLY WITH ALL NON-POINT Issued by:S4��&o Date `
SOURCE REGULATIONS,
Re-roofs
HAZARDOUS
Slgnnure of AppliuDau
HAZARDOUS MAng Occupant
DISCLOSURE Type of Roof
Will the aapplicantCupertino
or(ware building aceursin uom nr herdic HeaNra material
a Ocfinod by Uu Cupertino Municipal C .CNpur 9.11.end the Hullo and Safety
Idmo;
le,Section E553(s)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yn
I Will the applicant or future building Ott m use equipment or deviant which If a roof is installed without first obtaining an inspection,I agree to remove
It haardout sir mnuminantsssdcfia eB y Area Air Quality Management all new materials for inspection.
nrict7
❑Yes / n ;w_,t' 'l f,
IhrvcaeW theic,Sed s2550alamqulmmcnts 5534.IrCharster tood that ofthirthc Califon. 3— �
Hn t cumenfcryhave a notion.
it i my mord255Ea,l undersand that lfthc hoofing
not curtcntly,haw a unanr then itis my rcapoalhilily w nodi'the occupant M the
ulmm_ emuwhichmust be}}}ynnn Pin or,In.'�7umq�meCeninumofOc�ey�3 Signature ofApp ant Date -
ownerer_oorr`a0°k�agenti"r�l �.�1/✓' 1 oL -'S-�� Dam i All roof coverings to be Class"B"or better