02030068 (4) CITY OF CUPERTINO - ' I -•V - ',_, -
BUILDING DIVISION pERMI ,^CONTRACTOR INFORMAT1QN,:.:f
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BUILDING ADDRESS: PERMrt NO.
11567 COPPERSPRING CT GOSAL HEATING&AIR CONDITIONING 02030068
OWNER'S NAME: APPLICATION SUB DATE
TURUMELLA, BABU 2679 CHERRY BLOSSOM WAY 03/14/2002
PHONE:
(510) 441-2318 SANITARY NO, CONTROL NO.
O z Z ARCHITECT/ENGINEER:
O O BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
o. i L-J I'U L-1 1Lj
i Z L2 LICENSED CONTRACTOR'S DECLARATION Job Description
p 1 hereby aarm that 1 am liceamd under provisions of Chafe,9(commencing
w l_uJ 'with Secuxopfnc7000)of Divisiom3of the BJuCyr and Professions Code.and my license ADD 4 TON A/C UNIT
o w J L•innu1013s.and effect
.^ n 1 ness o a 9 1
g 4 a.»
e Co
L O:5
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ARCHITECTS DE RATION
g 1 understand my plans shall be used as pualic records
i a
80 Lmenxd Pmfesstowl t
•a� um. OWNER-BUILDER DECLARATION
1 hereby affirm that I am ecempt from the Contractor's License law for the'
k•?< following reason.(Seniors 7031.5,Business and Professions Code:Any city or county $3900
f S O which construct,a permit to consct,elmr.improve.demofish,or repair any structure,
out pdor,to ors issuance,also requires the applicant for such permu to file a signed statement_
that he ishemud pur'sudn{mrhe Pmvispm of the Contnetoss Liecrtse law(Chapmr9 /� - - - --
(co ro acagwith Scuion'? )of Division 3 of the Holiness am P,mfcasiom Code) \ r ga '{:t' Valuation
or Wm he H arm thdicfrxrrh.d Ne basis for the allegedpaemprion.An olation '1 1 r '3�'�' � ;�UV:?(l'"�' a s 3i
of Sea ion 1031.5 by any appliean4 for a Permit subjects the apPliemt to a civilPenaltyOf
not more than five hundred dollars(s5M). 204!"PNf6R'RRFLOOR F �E" Occupancy Type
01,as owner of the prop,rY.or my employees with wages as their sole romPen,ition, Ini _
'will'dl 'de work,end the'stmcturc is not intended or offered for sale(Sec.1044,' - _
Business and Professions Cade:The Canaaaor i License law does not apply to an 303 - ROUGH MROKk M64f£tions '
owner of propeny Who builds or improves thereon,and who does such work himself 304 - ROUGH ELECTRICAL _
or Omagh his own employees.provided Nat such improvements are not intended or
�oRcrcd for sale f.howeveCthe building or'improvcnrzni is sold within one year of --_- "' '
eompinion.the awnerbuilder will have the burden of proving that he did not buil)or 505 - FINAL ELECTRI CAL• .
improve farpupiof le.). 507 - FINAL PLUMBING
_ ❑Laapwaer project ro n,4a,Bur ti.and 508 FINAL-MECHANICAL;
---
' P Per r contracting licence<omm�ors to _..__ -...
onstmct the t Sec.]tYW,Basirmss and Profusions Code:)The Contractor"
t'•''' v
LGdwhLawe�`notapplytoanewnaorprepenywhobuiidanrimprove,thereon, 514 — FINAL PUBLIC .WORKS'
Gd who contracts for such projecrs with s contrxtor(r)licensed pursuant to.dm
_ CommctoYS License Low. _ .......... ... .__.... _._...._._._
❑lam exempt under See: � � � ,B&P C for this reason'- Owner Dacei aNnL
E-0
WORKER'S COMPENSATION DECLARATION
' 1 herebyeFrm under '" MAR
penelry of p£jury one of the following declarations: 11�Hav 1 .(I gaol
1 have end will maintain a Certificate of Cansem to self-insure for Worker's AR 9 L G
Compensation, as provided for by Section 3700 of the labor Code. for the BUILDING
l�U 1 L®iNG
t��
performancc of the work far which this parrot it issuW.
❑I have and will maintain Worker's Compensation Insu'rame ss required by Section
3]00 of the Labor Code;for the performance of the work for which this permit is
iaiued.My Worker's Compensation Insurance conic end Policy'numhiW-2-r-
are
4. ri^9'Pali>Na: q[148332s11 -
" ;•,CERTIRCATION OF EYEMPTI FROM WORKERb'r � l ;( 01" x: lr ' '`,"�:'r,.y�.. l t,', f
)._ ..
.. COMPENSATION INSURANCE " '"
This section need not he completed if the permit is for one hundred dollars
(5100)or less.)
I cenifY,that in the performance of the work for which this - - - - - -- - -- -
Permittto is issued,I
shall not employ any f C.Il in any manner so ax to become subject to the Workers' ..
Compensation Laws of Celifomia.Date
NOTICE
OTIAppliam
bemnaeETOv,1.APPLICANT,ker's Compenter sation
Ma Ccmfca¢in EsamprtodYou you old -
zZ becamemomply thesuchlsCompensation provisionsof thelabor Codayou must
0 foMwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY' - -
.' 1 hereby athroi that there is a consuuction lending agency for the performance
r� tti f the work for which this pcmut is issued(Sec:309],Civ.C.)
y Q
Lam der,Name
Z Lender's Address -
V g I cenify that I have mad this application and state that the above informaion is '
QW.Ea correct.I ogme to comply with all city and county ordinances and state laws relating
UJ to Wilding conswction,and hereby authorize representatives of Nis city to enter upon
�.t'tat the above-mentioned property for inspection Purposes.
(We)agree to save,mderimify and keep harmless the City Of Cupentrio against
Z, liabilities,judgments.costs and expenses which may to any way accrue eg.i.st said
V Z City in consequence of N gm ing of Nis perml, - v
AUL 'ITUNDERS AND WILL COMPLY WITH ALL NON POINT Issuedb
�y Y ate
Signet aof Applican—i-Lor Dae -
' HAZARDOUS MATERIALS DISCLOSURE Re-roofs
Will the g1thilam or Pomrc Nildmif Occupant srom or handle hazardous GroMfird Type of Roof. _
ai defined by the Cupertino Municipal Code,Chapmr 9.12,and the Health and Safay
Code.Section15533(,)^, '
❑Yes ..'> ONo
All roofs 'shall be.inspected-prior to any roofing material being installed.
,, Wdoolll the allc.nmommusasbuilding ed by upant useOn
.Air Qualitnt or y
vices arena, If a roof is installed without fust obtaining an inspection, I agree to remove
emit huLdaus ter contamir Na a defined by the Bay Ansa Air Quality Management
niatncn all new materials for inspection. Applicant understands and will comply with
❑Yes ON'c„3 - all non-point source regulations. -
I have read the hazardous materials requirements under Chapter 6,95 of thc -
California Health d:Safety Cade.Senions 25505.25533 and 25534.1 understand that
if the building does not currently have a mount.that it is my msponsibOty to naify the
scup o We rcquircme a who musty tact prior m issuance of a Certificate of
3 Signature of Applicant Date
caner or aathonmd agent. ore Al]roof coverings to be Class 'IJ" or better
:. . .:', ,.. :. . . OFFICE ...