03030147 (2) CITY O!'CUPERTINO .#BUILDING DIVISION PERMIT .0"QNTItCR�IN 'ORkA' TON
BUILDING ADDRESS: A PERFECT CLIMATE PERMITNO.
e3s� WAY
OWNER'S NA E: 10570 S DEANZA BLVD.TTM Wl4p.PT-ER
rEnmrr Ls
SANITARO. 2. O OL NO.
(408,) ,861-9545 Y
ARCHITCCTIENGINEER: - BUILDING PERMIT INFO
BLDGELEG7 PLUMB MECH .
0 0 0
"r`6LICENSED CONTRACTOR'S DECLARATION
1 wrxhy Allan that I..licensed under providon,of Chep¢r 9(commencing Job Description
with Seni l )of Division 3 ofthe Businetsand P fcasinns Code,.. m Been is v INALED
?� infullfom c
>�g Lin. w Le.. INSTALL FURNACE & ADD A/C
Dau: - T'DECLARATION
MAY 0 2 2003
e
ARCHITECT'S DECLARA
understunderstandunderstand -
y I understand my plans shell be v ec
used public rartlt � '
7 r
'0 Licensed Professional
OWNER-BUILDER DECLARATION' BUILDING
a 1 hereby affirm that 11. exempt from the Contractorsd License c Lew co the
2 O following mason.(Section 71131.5,Business and Pmfmssinns Code:Any city or county _
$ which myuhes Issuance.pomp re cnnwn,pima tmpmw,demolish,rat repair any ammo t
h,SS° pdmlits ensedpAmrequites theapplicantof for such Conrani'mimmerile a Law(hlement
�yxx< (commis licensed pursuant 7 the provisionsbof the ComnoorWcenmlaw(Chapter Sq.Ft. Floor Area I{1�[Ion
(common Ise empt shmn,from and of basis for of the Business and t Proon.Anynvi Code)of $1
1 V`l
�1 .. feet io Is exempt femrtff.m end Oat buts far fe@ As th, exemption.Any violation of
Section dam by Arty red dont fora 0B. mbjects Ne eppllant u a civil penalty of eD�7,}stw
notmortNanfiwhuntlrtddoilm($300). 34`L'7tllY19ter00 Occupancy Type
❑1,as owner of the property,or my emploYcw with wages a Nelr sole compenudon,
will do thew.rk,and feestmcmrt is rwtintendcd an offered fanale(Sec.70".Business 301 — ROUGH }}17T}�ddpp P1.S
and Professions Cock:The Contractors License Law don not apply In an owner of UNS ifections
property who builds.,ireprows feerton,and who doessuehwork himvlfor Uue.Shhis 303 - ROUGH M CHANICAL
own empioymw,provided that such improvements vent intended mortared foruk.If.
howewtthe WildingorimpmwmentissoldwiNmowe uofcomplNon.Neowncr- 304 — ROUGH ELECTRICAL .
builder will haw tbe burden of proving that he did not Wild or lmprow for purpose of X505 — FINAL _ELECTRICAL
sale,).
❑1,as owner of the propeny,am exclusively comae inA wife licensed commumns to 507 - FINAL PLUMBING
construct the Pmjwt(See.7044,Business ad Pr.feutons Code:)The Cont actors Li- 508 — FINAL MECHANI CAL '
men,Law docs not apply to an owner of property who Wilds or Improves thereon,and
who contracts for such pmjec%with a eomractor0)licensed pursuant to the Conuscurs
License taw. "
❑I am exempt under Sec. ,B A,P C for this reason -
Owner Dna
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of Perjury ane of Use following declaration:
It.w
wend will mdnuln a CeniBwuof Covenuo vlFlnmrt for Workers Campem
Ion,u provided for by Section 3700 of the Labor Code.for the Performance of the
work for which Nis permit is issued.
❑I haw and will maintain Workers Compensation Insurance,as mqulmd by Section -
3700 of the Ib.,Coda,for the performance of Use work for which N6 emit is Issued.
M)CF Co (nl�efavn3i` JJLtYnVIM „� '
C Policy Na.: S"-',�N
ERTIFICATE O EX PfION FROM WOR,y
COMPENS ION INSURANCE
(ThiswcOn need nm W cmnpI=d if the psUmb Is(mons hundred dnllan(glg)
or leer.)
1 cenify that In the performance of the work for which this permit ts Issued.I shell not
employ Any person in any manmrw n In become subject to the Workeri Compenudon
Laws of California.Dau
Applicant
NOTICE 7O APPLICANT:If.alter making fell Ccrtianu of EXMIUnn,you should
biome subject to the Worker's Compensation provisions of the Labor Code,you mon
Z forthwith comply with such provisions or this Numaltshall be deemed msmked.
z O CONSTRUCTION LENDING AGENCY
[rte I hemby affirm that them its c.mUuetinn lending agency l'nr the purformanca of
ai> We work for which this Permit Is issued(Sec.3097,Civ.Q
aQ Lender's Name
;)z Lwder'sAddros,
U Q 1 ccnily that I have read this application and mu that the @bow infonetiun is _
'Iy P correct.I agree to comply with all city and county ordinances and state laws relating to -
U buildio conswe(ion,and hemby authorize MPrtsematiwe of Nis City to cnur upon the
�a III A m mitund property for inspection purposes.
{r
P. ( c)agre saw,indemnify and keep humless the City of Cupertino a;aim,
i—i fn ablliR ,Judg rats coauandof this expenses which may in anyway verve agaiml said City
U`L neons-q,'ucn flh granting ollhis fermi(. //
^ PPLICANT STANDS AND WILL COMPLY f�WAITH AL NON-POINT Issued by: Date
U L Ns. tN
Re-roofs
igna urns p 'c on or Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
\krrrth'a CUrbm ser Nluni Wiling oceupapt nom.rand th Health A mauriat
u defined by 25 Cupertino Municipal Code,Chapur 9.II,end the Hcalfe entl Sefvy
Code,Section XN All roofs shall be inspected prior to any roofing material being installed.
Will the Applicant Or into building awupant UK equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It WxArdous air contaminants ss defined by the Bey Area Air Quality Management all new materials for inspection.
In
ict❑Yes Nn
1 have mad the huardousmaurials requirements underClupter 6.95 offeeCa ifor.
Ith d.iyCode,S duns 2550525533 an d2553s.lunkrazedthnlllheWilding n t curmmly hew a nL thatt it i m respond by 0 mlly the repent the
u an whi h mon pd pr w o niBuu of Geo
Signature of Applicant Date
wnef abnomixUlagenl Dare - All roof coverings to be Class"B"or better