00100216 (2) CITY wemy RTNo
BIL NPERMIT CONTRACTOR INFORMATION-
BUILDING ADDRESS: PERMIT NO.
OWNEICS NAME: APPLICATIORWDAS' -1
]ONE: SANITARY A: 3 1 into 1.%.
ARCH]ITC'fl1INGINEER: -7) A32 0123 BUILDING FERMI'F INFO
m BLDG ELECT PLUMH MECH
yah IJ D I=1 —I
Z N Z LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby.(Oran hat].in licc.sed under provision of Chapter 9(commencing
with Sulion7"Of Divoicar3of,he Bnsinessinl Profession Codaando,liorne
is in°t,W Q 1. endand effect.
M
a°a.y Dole Contractor CHANGE OUT OF GAS FURNACE, 70K BTU' S
ARCH]'1 IiCfS DECLARATION
SS understand I unJeJ my in plashall W used as public records
y 500 of Jt f:. Sul
n� OWNI R BUILDER R DFCI ARA1 ION
I heresy affirm that l ,u I III C t t L Law l'or the
I-' G whi It g IS•et 70115 1t fu r ! C l a y ly o,my
p5 y pcmu construct., II p he ott p y:t wSal
6 5 Q� port m t Is y th ppli I I' h pc 'u fl gest¢nem
mathhcar.dp...at tthe Iner,mon,,ofan CudhrrolLicenseLa (Chapter 9 S Ft. floor Area Vanion
(rat g with Seer 110) m 3 a 70of Division of the Business and Protession Cude) q' a
or In.,he is exempt therefrom and the breis Inr the alleged exemption.Any violtakat
of Station 7031.5 by any applieatn for a permit subjects the applicant to a civil penally
of not more than Eve hundred doUns,($500). APN Number �Occ p c e
❑I,as owner of the property,of my employees wish wages as their sole compensation.
will do the work,and the structure is not intended or offered for sale(Sec.APV, 38 GG 3
Business and Profession Code:Tmm
he Contcr's Lune Law aces not apply to an quired Inspections
owner of prolwny Who build%te improves tbercon.and who does such work himself
or Ihruugh his own employees.provided thin such improvements are not intended nr -
dntred fir sale.If,However,the holding(it iunprovetnent In Fold within one year rat 301 — ROUGH PLUMBING
hnngllo,lon.the owner-builder will have the burden al loosing that nedid not build nr 7
npmve ho purpose of sale), , — ROUGH MECHANICAL
❑I,us owner of the progeny,art exdunivdy contending with licensed commcmu In 304 — ROUGH ELECTRICAL
eon>wa the project(Sec.7014,Ensues,and Professions Coal,;)The Contracmr's n,
Licene Lose does not apply inan--.aridpropany who builds or improves therenn, 505 — FINAL ELECTRICAL
and who contracts for such Mojeals with a contractions)licensepuna..m the
Contactor',Livense Law. 507 — FINAL PLUMBING
❑I sin exempt umld See. B a P C Win,reason .508 — FINAL MECHANICAL
owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affmt under penalty of perjury one of the following Jeclmminns:
I have and will maintain a Ccel dice e of Content to wl f-insure far Worker's
ontpnrkmin I. as provided let by Sedloa 3700 of he Labor Coda. fur the -
ped'nnn:mce of the work far which this permit is issued.
Ell hove and will maintain Worker's CoaFvroatiml Insurance,as reyuired by sermon '
3710 of the Lobar Coda w
for the perfaronce of the work for which his permit is
sued,My W'orker's Compensation Insurance carter it Policy number are:
Carries Policy No,:
CERTIFICATION OF EyazMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This action need not be completed if the permit is for one hundred dollars
($100)or less.)
1 certify thin in the pedonandoc of(be work for which this groan is issued,1
,hall an employ any person in any u,norn sit us to Iwcome snucat I. it,WodcN
CntnTcn alien Lawsof California.Dom
Appli arta
NOliCI:TO APPLICANT:u:after muldng this Cenireaa of Ewundian.rant should
We be suhja,lh. he Worker's Gsmpcns.,ion p.... ni,of the Wbor Code.you must
0d,z fhwith ortcomplywin such provi,ion,or lin,permit xhall W deemed invoked.
,
E CONSTRUCTION Ireland NG AGENCY
I Ierebyrkfar which that there is a umod(Sea. 047.C agency for the performance
ofthe w Nedra which this permit is issue(Sea.3047.Civ.C1
6t Q Lender's Name
z Lender's AJtlrcns
V Q l certify that l have read this application and state that the above information is
W [moi csnrcct.I agree In coaddy with d1 city and County ordinances and state laws relating
V Inhandling const!union,and herchy authnrbc representatives ofthis any to enter neon _
>" W the uboo,c cntioned propcny for illvpcctinn purposes,
FF-t Cw (W'e)nmm
gro, vn,indcnmifp hvrnl
yand keeless the City of Cupatino against
7 ,
G hahuhiea,babons ms,cos,and expenses wLlah may In any way accrue ugannt said _
V LL1II City in maseyuonce of the stunting of this nnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINI'
SOURCE REGULATIONS. Issued by: Date
Signature of A,licanVC.on.a.r Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumrt nuilJingoccupant stole or haMle haradous material Type of Roof
as dctined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)?
❑Yea ONo All roofs shall be inspected prior to any roofing material being installed.
Will useapprentorfatorc building o«upon,.,a eyaipto mare dedees which If a roof is installed without first obtaining an inspection, I agree to remove
unit hazards¢,nircontaminaa,as dented by the buy Are.Alf Quality Munugantenl P g
..Tim all new materials for inspection. Applicant Understands and will comply with
°YeX °Nr all non-point source regulations.
I hose real the haeanlous m:neriols ingnirenurm,under Chapter 6.95 of the
California Heullh&Safely Crede,Sections255(15,25533 and 25511.1 untlentanJ that
if the building does not currently have a tinual,that it i,my responsibility to outify the
Iecupant of Ins requirements which meq he met print m isuuanec of a Certificate of
Occupancy. - Signature of Applicant Date
Owner orauthor.edagent Date All roof coverings to be Class"B" or better
OFFICE