02100084 (2) CITY OF CUPEWI'INO
BUILDING DIVISION PERMIT goCONTRACTOR INFORMATION
BUILj)L9jA2DoikENTWOOD AV AAA FURNACE & AIR CONDITI P6liM(02100084
OW0BR*HARDT IRWIN B AND NORMA rR1712 STONE AVE APPLICATIjr3MOp 2002
ONE: 4 Q 8 2 93-4717 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINCER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTORS DECLARA9'ION
z UF 1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing Oh D S
< with Sertion7aknnfoi,.- 3rflhe Baamesxand P<t reaaonaerde.andnty Bance is CHANGE FURNACE' & PA
in full form amlaflp �10
DyOZ✓, 1.itenWGyaa_ Lie.. JAN .
Fp Days U(O -nz Cnnuaclo,_ fes,, « ,2 8 2003
Y ARCIIITECI'S DECLA AK TION
yI understand my plans shall M used as public records 11 ,pV.
6 O a
u U �N�rD',Y
car
LiccnWd PrulcssinnalGG
OWNER BUILDER BUILDER DECLARATION
z a T I hereby affirm that 1 am exempt Tom the Contractor's License Law for the
iv 1:0 o following reason.(section 7031.5.Business and Profession code:Any city of county $6000
A m which requires a permit to ennahuct,alter,improve.demolish.Or repair any structure
rairinnan
o its issuance.also Oquires the applicant for such Permit file a signed statement
psoer� that he is licensed pursuant to the provisions of the Cunlmclors LicenW Law(Chapmr9 3T�.q 9E1.]f�cfm�AlQ� Valuation
~m (commencing with Section 70yfiof Division 3 mile,Business a ad Pru essitns Code)nr
y _
That he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant n a civil penally of
not more than fivchundred dnuars(su.n. 303PN-N&W36Pi_i PLUM IG ROUGH MEC CAL
Occupancy Type
❑ I.as owner of the progeny,or my employees with wages as their sole compensation.
will do the work,and the structure is nm intended or offered for sale(Sm.7144.Business T-1 ®-11
Spe�,(�
and Professions Cade:The Conuazmr's License law docs nm apply to an owner of 505 - FINAL Lel. 1l.Hy_,ODS
pmpeny who builds or improves thereon,and who does such work himWlf or through his
own employees.provided that such improvements are not intended uruffcred for sale.If. 507 - FINAL PLUMBING
however,the building or improvement is sold within one year of completion.Ne owner.
builder will have The burden of prevmg Bat he did not Wild or improve for purpose of 508 - FINAL MECHANICAL
sale.).
I,as Owner of the property,am exclusively convecting with liceottd concracmrs to
constrict the project(Sec.7f44,Business and Professions Code:)The Contractor's Li
marclaw docs not apply in an owner of property who builds or improves thereon,and
who contracts for such Commis with a contractors)licensed pursuant o the Comractois
License Law.
ElI am exempt under Sec. B as P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain aCenificate of Consent to sclf-insute for Worker's Compen-
.'let,as presided for by Section 37W of the labor Code.for The performance of the
work for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance.xx required by Section
)of the Labor Code,for the performance of the work for which this permit is issued.
My Worke!!',Compensat/eum Insurance carrier ad Policy number a:_ f
Carricr.J �� /LN�I Policy No.: 7 7.'�J
CERTIPIC 9_ E%EMTUNFROMWORKERS'
COMPENSATION INSURANCE
(This accuum need not be completed if the permit is foronc hundred dollars(SRM)
nr less.)
I certify that in the Performance of the work for which this permit is issued,l shall net
employ any person in any manner set as to become,,uh mI hr the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL aper making this Cenilicalc of Exemption,you should
become subject m the worker's Compensation provisions of the Labor Chad,you must
O z ford with comply with such provisions(IT this permit shall he deemed revoked,
Z O CONSTRUCTION LENDING AGENCY
[--� l hereby affirm that there is a connmetion lending agency for the performance of
S' the work for which this permit is issued(Sec 31)7,Civ.C.)
d0 Lender's Name
z Lendeis Address
Li, 0 1 rectify that 1 have read this application and cute that the stave ws relating is
U building agree m an.plyand with y arem and county ordntativ s offus and stay sent relating the
QU abovenmentioned
ennswmion.and he¢hyauthon resentativcxofthiscitymercerupon the
W ahovcmc e)agree
to c property lin inspection ankeeppurposes.
Ty We)agme to can,indemnify and kith harmless the y m of Cupertino s against
y Iacoisequence f ts,the granting of
expenseswhichit. may in anyway seethe against said City
rJ z A consequence UNDERSTANDS
of This term it.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Dale
SOURC REGULATIONS
c 2
lis of ApphcanUComracmr a Re-roofs
HAZARDOUS M TERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle havardous material
n defrred by IM Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CIAO.Section 25532(a)?
E]Yes �No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building oecupam use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
out bayardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dlslrifl?
❑Yes -NRu
I have read the havardms mayrials reyuircmcnts ands,Chapter 6.95of the Califin.
nix Heabh&Safety Cod,Sntions25505,25533 and 25534.1 understand that fluid building
does not cumentiy have u tante.Thal it is my no,,ne ihility m Truly the uccup.,of the G
requite ntswhich on.hemet poor Toisaanceof.ccnificid] apany. SlgriatureofApplicant ase
Owner oramum t CI Dat All roof coverings to be Class "B" or better