01010069 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS'
20564 KIRWIN LA VALLEY HEATING & C66EMB 01010069
OWNER'S NAME: APPLICATION SUIT )Am
MARSHALL CHARLSIE M 1171 N 4 TH ST t�11/18/c001
14 I'HONF (408) 294-6290 SANITARY NO. CONTROL NO.
wOO
ARCH]I'EC'I'/ENGINEER: BUILDIK[i PERM)F INFO
. BLDG ELEM PLUMB MECII
U I-1 I-1 CI 1=1
�«
z�yZ LICENSED CONTRACndDECLARATION Job Description
14 1 Intent aRrm mat L ads licensed owererpmui.Pons of chapter 9 kantmenemg
„ w witnStt'tion7gX)lufDivisionJolmcllvincscondP fess^mCW 'nJ tylcenx FURNACE REPLACEMENT
force and e}�d.
zt2 tea. ens=Clj.,-_aji /O� I.ic,p �/ _
w 3 C not ,it 11
a. IARCHH]Ul S DIiCLAK N
'=O 1 ondeatnnd my plan,'(tall ho n.vcd:",,optic modals
a 5 p O Jocnncd Po*Nsloral
OWNER-BUILDER DECLARATION
w ,n I hcfcby affiant thin I:nn e.ent,Gunn the Contructor's Linen's Law for the
C z< browin,A,asna(Section 7031.5.Business and Prof—lone Code:Any city or county
E x❑ whim mryires a permit to construct,ala¢improve,demolish,or repair any structure
nam porta its issuance.also reyuimsthe applicant far such permit to file a signed statement
that he is licensed paasuunt to me provisions of the Contractors License Law(chapter 9 Sq. Ft. Floor Area / I
(cammendng whh Seeman 7uX))of Divieian 3nf,he Basions,and Prmee.ians Colic) - 3200
or that he is csempuherefrom and the basis for the alleged exunption.Any violation
of Section 7031.5 by any applicant for a peanut subject,the applicant It,a civil penalty Of
of not more than five hundred dollars(s5(X)). APN Number BVi pp Bey Type
01.as).nc,.l he propcd.nr„ryerltpJi,ec, intrages.,mic.,wee,an.....nlion. - 359'23013. 00 /
will Jo the work.and the sho dare is not rounded or offctcJ bn sale(Sec.7044.
nusinae and Prafxdnnx Crn1,'fne Conuualar's Liecnee Law dos,not apply ro nn Required Inspections
owner of property Who baNm
dshnproves thereon.and who does loth windsltinn,au 204 — UNDERFLOOR FRAME
oioup”his own erupicyrc,.prnvhicd mar sae 1,impnry re ems aBat intended nr -
llcued for,wc.u:hawe,er,Vne budding or ouprove,ncrtt l'zdd within one year of 301 — ROUGH PLUMBING
completion.the oxmef-builder will have the burden of proving that be did Bat build or
dnpanvef pa"'Odfww.)' 303 — ROUGH MECHANICAL
0 L as owner of the poper,our exclusively contracting with licensed contractors 304 — ROUGH ELECTRICAL
construe, prove,the pve,sec.TW.Business and n
Pmtsian.Code:)mdu
e Conctor's
LicroeLawdoesantapplytoana act of property whebuildsorint,rovesdtnrean. 505 — FINAL ELECTRICAL
can who contracts for such project,with a contractor(.)licensed pursuant m the
mttmanr,L.icenseLuw. 507 — FINAL PLUMBING
❑I or exempt under Sfc. .B&PC for Ilia"amt 508 — FINAL MECHANICAL
Dwrrer WORKER'SCOMIPNSAI[ON DECLARAIION 514' — FINAL PUBLIC WORKS
I baeby adore order penalty of Perjury o u.of roc farrowing dedino nn i
❑ 1 have and will maintain a Cvnircotc of consent to,clf-iusarc list Worker's
Compensation. as provided fm by Section 37(X) of the labor Code. 1nr due
perfnrnunce of the and,for which this permit is issued.
01 have and will maintain NbrAcr's Compensation Insurance,as reyuireJ by Section
37 f the Labor Code,far the perfomtance of the work far which his permit is
.sued M ode; nwdioolyyyy�urencecariaand POILeynumbefam:
m e (policy Nn; -
CER'IIFICAnON OF EXEMlsl ION FROM WORKERS'
COMPENSA'HON INSURANCE
(1 hi,s,onsu need Inn he.... fl,,d it rhe permit Is far one hundrrd dollars
(S 100)o Ica.(
1 certify that in the performance of the trials for which this frond is issued 1
shall aid crnploy any person in any manner so as to hccanne subject to the W alwo,
Compensation Laws of Caliocardo D:nc
Appllcmn
Nm'ICIi'rO APPLICANT.If,after making this Cer iticae of E,emptian.You should
heaonte.uhBcl u,the Wod.ers Cnmpernainn prawroom of the Lala,Code,you Bust
Q 0 fonhwidh comply with such provisions or anis pcmtit shall be deemed revoked.
FCONS]'RUCI'[ON LEND I NO AGENCY
a , 1 herehy affirm than there is a on,trnmion lending agency for the perfortnance
01 he work 1'or which his perinin is...0cd(See.3097,Or,C.) ,
0.. Q LenJa's N:une
;D 7 Lcndcr'a AdJres.,
V 0 1 eerily that I have read this:ygficmino ani state thus the above'm lonoatin 0 is
Is F.• conttrt.I agree to comply with all city and county ordinances and state laws relating
Q U rebuilding cnndanction,and hereby aaborDe rcp,esetru,ive,of this city b,enter uptm
} W the ohne-nicnuonod property for inspection pro"oe'.
E.• a. - (W'e)agree in save,indemnify and keep harmless the City of Cupertino against
VJ liabilities,judgments,cow and egwnms which may in any way accrue ugaims said
f„) Z City in run.cyucnce of the gmnf g of th,,candid.
SOULICANTf red 1 ND. ND ILL COMPLY WITH ALL NON; INT 'Issued by: Date
grist nr pp iLr Re-rXhalll
HAZARDl1U5 MA'I'IiR1AL5 IlISCLOSURf?
Will
dw:"'(cant as Inane nnld'rrtg uecarpnm care as hnmue Ban.:rrdna,rrr:rtedw TypersddraJCaul,Seen 125532(a)'uOYe, 0No All re inspected prior to any roofing material being installed.
Will the applicant or fuum bolding occupant use ryuiptnnn nr device,which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hazardous air canmminann as dcforA by the Bay Area Air Quality Managanent
District. all new materials for inspection. Applicant understands and will comply with
0 Yes ON' all non-point source regulations.
I have read the ht,ardom mmcrials requirements under Chapter 695 of the
California Health&Safety Code.Sections 25505,25533 and 25534.1 undcm:md than
it the building Joe,not currently have a tenant,that it is my tugtasihility to nodi fy the
,scup' of the rrynlrcmcnls hitt prior w i,,w:mac of it Canilicme tai'
SignahueoPApplicant Dale
1 r Inaocd agaal —' Dare
�1— All roof coverings to be Class "B"or better
OFFICE