02100019CITY OF CUPERTINO
� � ' '�-
BUILDING DIVISION PERMIT
, CONTRACTOR ILVEORM'ATION: ^^
Bull 1 IsWHEATON DR
PERMu'Nf02100019
OWIfMR/WA PAN
APPLICATI(1FJlstaRY7 2002
//
IONS:
SANITARY NO, CON'IAOLNO.
ARCIIFIEC' YENGINITER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I hereby aflirm that l am licensed under provisions of Chapter 9(commencing
REPLACE FURNAC!e DescriptjQp'�ALECa
e Bness it Profess re, Codcand my her.. is
with Section]IXM)of Division lof musi
ue.;r�" /
1'�
(80000 BUTH)
t ARCIIIT'IiCTmr �CLARA ION
OCTQ
C O 8 2002
1 understand my plans shall M used as public records
Licensed Pmressinnal
DECLARATION
OWNER BUILDexempt
BUILDING
1 hereby alfirm that I am exempt from Inc Contractors License Law lin the
fr
following maam (Section ] Business and Professions C county
Any can
h, or s
requires a permit construct. alter. Improve, demolish, repair any structure$2500
whichamissuance.
prior to am issuance,also re tires the file
applicant forsuch Icrmiuo lienssigned mmcmcm
Sq. Ft. Floor Area
Valuation
that lin i.s heenee por.saatu b, dre pm�iahrn.s offin, nrmmmar'.a License Law lcnap,cr9
towthe,
(commencing with Section ]f nfi of Division 3 of the Business and Professions Gds) or
3 1623055.00
that he is exempt therefrom and the Kazis far the alleged exemption. Any violation of
APN Number Occupancy Type
Section ]031.5 by any applicant for a permit subjects the applicant m a Civil penalty of
not more than five hundred mmars(9510)'
301 - ROUGH PLUMBI G
❑ 1, as owner of the property. or my employees with wages as Flow sole compemation,
will do the work, and me structure is not intended nr offered for sale (Sea 7004, Business
Professions Co dhe The Convenor's License law does not apply to an cont of
ROUGH4Lc gFp1ktions
and
property who builds or improves thereon, and whodoes such work himself or through his
own employccs, provided that such imprraemeres are not intended or offered for sale. If,
3 04 -
505 — FINAL ELECTRICAL
however, the building or improvement issold within one year of completion, the owner-
507 — FINAL PLUMBING
Wilder will have On, burden of proving that he did not build or improve for purpose of
sale.).
508 - FINAL MECHANICAL
O 1, as owner of one properly. am exclusively contracting with liceaed contractors to
nsvuct the project (Sec. 7114, Business and Professions Code) The Core racmr's Li-
cence, law docs non apply m m owner of property who builds or improves drerm n, and,
who comment for such pri with a contracmr(s) licensed pc rsuantto the Contractors
License Law.
C1 1 am exempt under See. . B & P C for rnsom
OwnerDam
AT
WORKER'S COMPENSION DECLARATION
I hereby aRrm under penally of perjury ane of do following declarations:
I have and will maintain a Cenibuam of Conserv to self home for Worker's Camper-
-him, as p,.video Tor by Section 3700 of the labor Code, Ino the performantt of the
work for which this permit is icard.
1 have and will maintain Worker's Compcnvation Insurance. as required by Section
3]q) of the labor Crate, for the performance of the work for which oris permit is issued.
My Workc sCnmpcn.salion ln.sumncc carrier and Polity n an ''2:0015%/�
ec�i yN' PulicyN1Zq-oz
Carzico
GIitoBI KIE Io EXEMPf10NF QMWORKERS'
COMPENSATION INSURANCE
(This sectilm aced not be completed if Bic rcrool is for enc hundred dollars(SBg)
,it Icxs)
1 eenify that in the lefforem nee of the work for which this permit is issued, I .shall not
employ any person in any manner sit as m became Subject o the Workers'Compensation
Iawsof California. Dam
Applicant
NOTICE TO APPLICANT: Ir, al ler making this Cron licale of Exemption, you should
Itecome subject to the Worker's Compensation provisions of the Liber Code, you must
forthwith comply with such provisions nr this permits shall be deemed revoked,
CONSrRUCI'ION LENDING AGI7NCY
I hereby affirm that mere is a conswction lending agency Inr the Performance of
the work Tor which this permit is issued (See 3097. Civ. C.)
lender's Nam.
Lender's Address
and state that the above interaction, is
I eenify that I have mad This SURctat
l
city and coon ane mm law, relating It,
niece. 1 agree m comply with all city and county ordinances
building construction, and hereby aufami ,mpracnwlmes of this city In enter upon the
above-mentioned for inspection purposes.
properly
(We) agree to save, indemnify and keep hetmless the City of Cupertino against
V
Iishil itics.judgment, costs and expenses which may in any way accrue against said City
in aonscqucnce of me granting of this Permit.
APPLICANT U ERSTANDS AN WILL COMPLY WITII ALL NON -POINT
A
Issued by: Date l I
SOU A'I'IONS.
e roofs
Dale
ignar cnMPPlicanUCo 'ntc
IIAor BOGUS MATERIALS DISCLOSURE
Type Of ROOF
Will the applicant or future building occupant entre or handle
Health and
as Uchnet by the Cupcninn Municipal Costes Chapter 9.12, and the Health and Safety
MuniMunicipal
Code .Secdon25532ad'
Yee NNo
All roofs shall be inspected prior to any roofing material being installed.
p
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
mit haeardnua air contaminants as de iced by the nay Arca Air Quality Management
all new materials for inspection.
District?
Yes �No
I have read the hamrdousmaterials reyuimmenm under Chapterb.95 of the Cakfor-
.is I(calm & Safmy Cale. Scene. 25515, 25533 and 25534.1 understand mm if the building
teas not currently an a mater, tit is my mspurau ility at notify the on., of the
int," ichmrnla:mn an Ioosammcnfa Cenllic nfacllp, /'
Signature Of Applicant Date
I !/
All roof coverings to be Class "B" or better
Owner or mo i,d crl Date