01070023 (2) NO
CITY ofcDPv sOiN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
6685 CLIFFORD DR CONDITIONED AIR 01070023
1ff FARMSTRONG 164 B GILMAN AVE . 07G�10 200E1
iPHONE: (408) 374-6311 SANITARY NO. CONTROL NO.
O O ARCHITECTIENGINEER: BUILDING PERMIT INFO
pp BLDG ELECT PLUMB MECH
<i 4 C L=1 1=1 LJ
z ro=KK LICENSED CONTRACTOR'S DECLARATION
�• �T�of�s Description
O z— I hereby aRrm that 1 am licensed under provisions of Chapter 9(commencing FURNACE CHANGED V rl ,
t:,HFW with Section 7050)of Division 3 of the Business and Professions Code,and my license
<m is in full force and effect.
6
Ou,XLicense Class Lic.p
a�e 3 Date Cmumuctr
ARCHITECT'S DECLARATION
C th ,aj 1 understand my plans shall he used as public records
of z p Licensed Professional ( j:
°' OWNER-B DECRA'WN \ '
m= 1 hereby eflirm th tTito
[ [h on[ri wr We rase l.aw� [fFe • 1
Y a following reason (Sttuon] min
Popf ss on Code/toy ti r my - $688
wh h q s a peon t[ t Ita impro v d mulish dkpu r v I to
a 3 `Pet I t i s once vkoreqapplcanrtorsuchpermmofl asg tate t - Valuation
that he tsl enietl puisuau sofm Contract f L Le h r9
nDivision 3 a((((((the mint and Prates ns Code) 7s , ,PP •1,•_1T(I s +,•
or that he is exempt therefrom arJ the bests fair el� rotation Any violation
-of Section 7031;5 by any applica fora bjectst applicant a civil penalty
ofnormarethanlives hundred do u' 30JAP-n NoUigHl PLUMBIN Occupancy Type
❑1.as owner of the property.or my employees with wager as their sale compensation. 303 - ROUGH MECHANI AL
will do the work,and the structure is not intended or offered for sale(sec.]IW: TTSS11 Yy6+
Business'And Professions Code:The Contractor's License Law does not apply to an 304 — ROUGH ELIgMJJa CA4ctions
owner of progeny Who builds or improves[hereon,and who does such work himself 505 - FINAL EEE TRI CAL
or through his own employees.provided that such improvements are not intended or
offered for sale,IL however,the building or improvement is sold within one year of 507 — FINAL PLUMBING
completion,the owner-builder will have the burden of proving mat he did not build or
improve for parposeofsale.). 508 - FINAL MECHANICAL
muarroo❑Las owner of the progeny,em exclusively commning with licensed comrscmrs m ..
_ cicensetheoesno(Sec. to a Business adProfessionswho b Code:)The Contractor's
License law does not apply man owner of property who builds sed p Improves thereon.
..and who wormers Iorsuch.projats with a-convacmrts7 licensed pursuant to the _
_ Comradarx License Law. .. .. _ .___ .... _ -.. . . -.. . . ....
❑I am exempt under Sec. B&P C Ratio...an -
Owner Date -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
- O I have and will maintain a'Ceoificme of Consent to self-insure for Worker's
- Campensedim, as provided for by Section 3700 of me Labor Code, for the
performance of the work for which this permit is issued.
❑1 have acid will maintain Worker's Compensation Insurance.as required by Section
3700 of the Libor Code,for the perfomance of the work for which this permit is
issued.My Worker's Compenkatton lnmrance carrier and Polirynumbcrarc:
Carrier:' ;,` ' '. .".:Policy Ho.r
CERTIFICATIONOFEXEMPfIONFRDMWORKERS'.' •s '•'"SC� -• s - '
COMPENSATION INSURANCE'; �'
7.1
�'(ibis union need not be eampineA if the pemris is for one hundred dollars
(5100)or les.)
I certify alas in me n in any manner
the dark for which this permit a issued.1
shall not employanyperson in any manner ad as m become subject to the Workers'
Compensation Laws of Cvlifamia.Date'
-Applicant
NOTICE TO APPLICANT;If.after making this Cenifcate of Exemption,you should "
become subject in the Worser's Compensation provisions of the Labor Code,you must
forthwithcomply with such provisions orchis permit shot)be deemed revoked.
f ^ °,t • ' �'
CONSTRUCTION LENDING AGENCY
ai > 1 hereby affirm that there is a construction lending agency for the Performance -
W of she work for which this permit is issued(Sec.3097,Civ.C.)
LL (] Lenders Name -. .. .. . . . .. .. .. .... .. . ..-
=,z Lenders Address - -
V 1 certify the I have read this application anJ suue Nat the above infomution is
carat.I agree to camply.with all city and county ordinances and state laws relating
�.V to building construction:and hereby motion u repesentadves of this city to enter upon
the abo(We)agree
to property,rode r i indemnify
and
puryoses. �
FL es,j ag m save, and exfy d keep hmmy in the City of Cupertino against
-pl liabilities,judgments.costs and expenses which may in any way accrue against said
C,1 Z cityi rmcaquence of the granting ofthis pooh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
- SOURCE REGULATIONS.
Signature of ApplicanOConorwor - Dau Re-roofs
HAZARDOUS MATER1AIS DISCLOSURE
Will the applicant or future building occupant stoic or haMle hvallous maurial Type of Roof .. _ - - ". -. •• -
as de0ned by me Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Swion 5532(a)".:. .. ,.. :•, , r .. . . : ' . . . .i
❑Ye's r• % DNo...
_ All roofs shall be inspected prior-to.any-roofing.material-being installed. __._ ... .
\Yll the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection',I agree'td'remove
emit harardous air contaminants as defined by the Bay Area Air Quality Management
District all new materials for inspection. Applicant understands and will comply with
❑yea, - 0 N all non-point source regulations.
1 have read drc hazardous materials ogmmuncrits under Chapter 6.95 of the
California Health&Safety Code.Swims 25505.25533 and 25534.1 understand that
tithe Wilding does not currently have a tenant,that it is my responsibility to notify the
vca,.,of the fequiremems which most be met prior m issuance of a Certificate of
Occupancy.. Signature of Applicant _- Date
Owner or aathmmed.gear Date All roof coverings to be Class `B" or better
...
7 - - OFFICE .