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02110109 (2) CITY OF CUPEIrfINO '0;r" BUILDING DIVISION PERMIT CONTRAC"TOR INFORMATION:" Bul IIRENCOLUMBUS AV A & H HEATING PERMITN02110109 GWM 1'Q1IhNTOSH JOSEPH R AND SUE C 770 CHESTNUT ST APPLICAT11y1151d B1D8Try2002 I ]ONE: 406 270.0722 SANITARY NO./ 7 CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �00 LICENSED CONTRACTOR'S DECLARATION CCdJ Iherchy affirm Out lem licensed under provisions of Chapter (rommerreing REPLACE FURNAAb�es oW/C with Section 711(Ily of Division 3 of the Business and Professions Code,and my license is F in full force anJ elle g: LieenmGl^a Lic.g FINALED 0w Date Contramr H<v ARCHITECTS DECLARATOR 60 U Iunderstand myplans shallthe used aspublic recnNs DEC 11 2002 u�3w Licensed Professional ta05 OWNER-BUILDER DECLARATION 1 herthy affirm that I am eacmpt from IM Conuamnr's License Low for the ���p� 7 0 following mason.(Section 7131.5,Buamess and Professions Code:Any city or county o.Ei$ which requires a permit Or construct,alter.improve,demolish.or repair any structure rZ� prior m its issuance,also requires theapplictim orinch permit m file.signed statement 5 < that he is licensed Poonmod 11)the Provisions of the Contractor's License Law(Chapter 9 3*66t8f©bb6A@® Valuation of $ (commencing with Section 7000)of Division 3 of the B usiness and Professions Code)Or Out he is exempt therefrom and the buts for Ne alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penally OfPMN Occupancy not more Him BVe handred dollars($500). 303 - ROUGH MECHANICAL p y Type ❑I,asowner ofthe propeny,ormy employees with wagtsasd¢u selecompeuation, will do the we&.and the structure is not intended oroftee od formic(Sec.7014,Business3 e4 '8H - and Professions Curie:Th.Caroni Lianm Law dots not apply m an owner of 501 - FINAL R!10'09NERGY property who buildsor improves thereon,and who doessuch work himself or through his own employees,provided that such improvements am not Intended or offered for sale.IL 502 - FINAL PLUMBING ENERGY however,the building or improvement is sold within one year of completion,the owner- huilder ,will have the burden of proving that he did not build or improve for purpose of 503 - FINAL MECHANICAL ENERGY rots.). 505 - FINAL ELECTRICAL ❑I,as owner of the property,am exclusively communing with licensed convectors to 507 - FINAL PLUMBING construct die project(Sec.70,14,Business and Professions Code:)To,Convacrols Li- censeLawdoesnotapplymanownerofpropenywhoWildaorimproveslimmon,and, 506 — FINAL MECHANICAL who contracts for such projects with a convaetor(s)licensed pursuant to the Contractor's License Law. C I sur exempt under Sec. .B&PC(othis much Owner Dam WORKER'S COMPENSATION DECLARATION I hereby aRnm under penalty o(perj s,one o(0,fallowing declantiune: ❑ I have and will maintain aCenificate of Consent wsel6insum for Worter's Compere anion,as provided for by Section 37M of me Labor Code,for Ne performanm of the, W ork for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 37(p of me Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insmana carrier and Policy number are: Carticc 7Q-41 LLIC Policy No. 20 67 CERTIFICATE OPTION FROM V'OR ERS' COMPENSATION INSURANCE IT Itissecthm need not lecomplered if the Permit is fortune hundred dollars(g1000 ,it lest) 1 codify that in the performance of the work for which this Permit is issued.I shall not employ any Person in any manner so as to become subject to the WorkersCompensation Laws of California.Date Applmanl NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should become subject to me Workers Compensation provisions of the Labor Cook,you must OO forthwith comply with such prnvisioos m this Iacono shallvo W deemed reked. z CONSTRUCTION LENDING AGENCY [.. r Iherchya0irm mat mere is a construction lending agency for the perticmancc of Ci the work for which this Permit is issued(Sec.YN7,CO.Q aA Lender's Name z Lendcr'a Address U Q 1 cenlfy that 1 have read this application and mutt Out the show information is P: correct.l agree to Comply with all city and county ordinances and state laws relating toQU Wilding Conswction,and hereby authorim mpouenlatives of this city to enter upon thc W mrive-memioned property for inspection purposes. 0.t (We)agree,to now,indemnify and keep harmless the City Of Cupertino against / rA liabilities,judgments,costs and oC,snms which may to any way acerae agal nn mid City U 7 in consequence of the granting of this Nobil. F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs HAZARDOUS Signature df ApplicaHDam AZAR0O05 MATERIALSDISCLOSURE Type of Roof Will me epCupert ser future building occupant stem or handle Health and as defined by the Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety 41 Code,Section 25532(a)'! All roofs shall be inspected prior to any roofing material being installed. 0Ycs QTr Will the applicant or future Wilding occupant use equipment or Jevias which If a roof is installed without first obtaining an inspection, I agree to remove emit h.dous air emitaminaneu defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes G�tb I have read the Wrardous matenals reyuircntents under Chaptcr6 95 of me Califor. nia Health&Safety Code,Sections 25505,25533 and 255W.1 understand mat if the building does not currently haw a tenant,that it is my resmmsihility to notify the occupant of the ¢yuimm nts which muslbemet poo oiuuytcc tufa Ccniu�`Q�uPanexJ Signature of Applicant Date Owner oraumonmd.,Or •'C// � DKate All roof coverings to be Class"B" or better