05010100 (2) CITY OF CUPS RTINO r o 0
BUILDING DIVISION PERMITCONTRAC�T®RINFORMATI®N
�. .,
BUILDINGADDRESS; RESIDENTIAL HEATING AND A/ ErtnN`D5010100
33 CHRISTENSEN DR
W NER'S NAME: PERMIT ISSUE DATE
ROBERT SCHAKOW 65 CRISTICH LN 01/18/2005
NE: SANITARY N0, CONTROL NO,
4083774073
AR CHITECTIENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I00 LICENSED CONTRACTOR'S DECLARATION'
m❑ I hereby affirm that 1 am keened under provisions of Chapter 9(commencing Job Description
�<a. with Semion]OIM))af Di "on 3orthc Business and Prufcssin.0 d andmyliccnu is ff� f� /� �r��
a. I.mu rare'a^d eq«L 'n 1�� (� REPLACE FURNACE 1lh�lI INA
'ILphy
jLlZ Licens�Clay�—��`�Lic.p II
Date Cantncm, C ka s_ o r%T1 es - -PLA Ot
J ARCHRECTS DECLARATION J
I 'u IunacrslanJmyPl.an d s M1llC records
JAN :Vo 2005
Ucensed Paressianal
`0< OWNER-BUILDER DECLARATION ���r���J�/\,Ir1If 111111
L J\VJ
<S 1 hereby affirm th.I am exempt from the Contractons License Law for the
0 0 following reason.(Section 7031.5,Business and Profession Cole:Any city or county
m which requires a permit to construct,alley,improve,demolish.or repair any Structum $2127
Zr prior In its issuance,also requires the applicant for each Permit rile a signed ettemcnt
< that he is licensed ...a,tameProvatansofthe conteaLmn:uana<Lw(Chapter 9 Sq.Ft. Floor Area alua[ion
rP� (commencing with Section 7000)of Division]of the B usincss and Prorcssions Code)or
that he is exempt thmefrom and tint basis for rite alleged exemption.Any vialation of
Section 7031.5 by any applicant for a Permit the applicant to a civil Penalty of er0 0 Occupancy Type
not more than firs hundred dollars(M).
1,as owner of the progeny,or my employees with wages as their sole compensation,
will do the work,and Is,swcture is not intended or offered for sale(Sec.70,1n,Business
and Professions code:The Conmctnns License Law does net apply m an owner or Required Inspections
property who builds or improves thereon,and who doessuch work himselfor through his
own employers,provided that such improvements are not intended or offered for sale.IL
however,the building or improvement is sold within one year of completion.Ne owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contacting with licensed contractors to
construct the project(Sea 70,14.Business and Profusions Code:)The Contractor's Li.
cone Law does not apply to im owner of properly who builds an improves thereon,and.
who contract for such pr*cu with a contraclons)licensed pursuant m the Contnctons
Lice arr Law.
❑ I am aempt under Sec. .B&P C(nr this reason
wnct Data
WORKER'S COMPENSATION DECLARATION
\ Ihereby affirm under penally of perjury one of the following declaration:
1 have and will maintain a Cenifcam of Consent self-insure for Worker's Cormier.
salion,as provided for by Section 3700 of the Labor Code,far the performance or the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
J] or the labor Code.for the performance of the work far which this remain is issued.
My WorkCedCompensation
�Insunrra Inion end Policy number art:
Cann t:r.YtR"tR, i-k-L f�L� Policy No.:r]b 'U qS l(`5
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wLlinn need nut he compincd it the Permit is for ane hundred dollars(g1IX))
ar less.)
1 ceniry that in the performance of the work for which this Permit is issued.I shall nor
f em
�(`i'{s Laws of Cploy any,pe in any ma net asmbe me subjeolmtFu workers'ComPensalinn
/\ }lif�n Datc
Applies.`V-ti tiA
NOTICE TO APPLICANT:IL making aking this Cenirinm`5of Exemption,you should
become subject to the Workers Compensation provisions of the labor Cad,you must )
DQ forthwith comply with such nativism.est this Permit shall d demand smirked.
Z CONSTRUCTION LENDING AGENCY
1 thereby affirm that there is a construction lending agent,for IM performance of
Q4 the Werk fur which this permit is issued(Sec.](197,Civ.C.)
D0 Leaders Name
,z 1<nd'1 Adtifyt
J I ranee that I pars read this application and state that the above information relating is j
y (~ bunco.I agree m comply with all city and county ordinances and sole laws relating m
�U ithave-menti ped constand ruction, a.honlimptesentlives of this city to enter upon the
^ 0. alcove-mcmioncd ProPcrtY far inspection purrwscs.
(We)agree m save,indemnify and keep harmless the City of Cupeninu against
Z inconsequenc judgments.coming exposesmay in any wayaccrueagainst said City
;J ,'� Aconsequence of the UNDERSTANDS
Permit.WI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S RCE REGULATIO�� �,�,� �
' 1"�✓�-A-^k-0 Re-roofs
Signature of ApplicantConrtamor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or felure building occupant stone or handle ha'rmdous material
as defined by the Cupertino Municipal,Code.Chapter 9.12.and the Health and Safety
ode.Section zssula)7 All roofs shall be inspected prior to an roofing material being Installed.
Oyes ON. P P Y g g
Win the applicant or future building occupant use equipment Dr devices welch If a roof is installed without first obtaining an inspection,I agree to remove
nil hanrdnis air contaminants u dGncd by the Bay Area Air Quality Management all new materials for inspection.
Diane's
❑Yes ON.
I have read the hmardousmamriat mquimmonu undr Chapter 6.95 of NeCalifor-
nia Health k Saf.yCodb,Srcdo.255)5,3553]and 255},1,1 undrsund Nat irthe building
dors ain surreally have a tenant,that it is my responsibility m nndly rile mcupwl of Ne
.antwhich must bemePrinmiastanLe_aracea;oLitLarVirancy. Signature of Applicant Date
ownbr or authorized ase. �,�5 All roof coverings to be Class "B"or better