01020031 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
13I ILDING ADDRI',SS: PBRMI'INO.
21447 KRZICH PL SOUTH BAY REFRIGER TION 01020031
OWNER'S NAbllf: APPLICATION SOH DATE
HELENHO 461 PERRYMONT 02/06/2001
PHONE: SANITARY NO. CONI ROE,NO.
(408) 279-1911
G W Z ARCIII'1'LC17HNGINEEII: BUILDING PERMIT'INTO
P o oO❑ HLOG IiLliCl' PLO MUCH
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han lob Description
OG p 1 hereby ul'Ifnn Ihul Bin IlcmncJ muter prnvlsinns of Chapin. d y 1ecano, .
F-y C y w, tlinn 71XM)of Ilivisinn l rel me Haziness mW Prolessinn,C W nJ my license
att mmnfamerm D � REPLACE EXISTING FURNACE WITH 900, 00
tt tt V :cense ClT Lic.b
3 LL y Uatc -
f—LL• j ARCHITECToS DI-CLA N
pine ntJnPublicressJx FI N
dLCD1 undcr,tand my
Y
Licensed Professional
o OWNER.BUILDERDHCLARA'1'ION JAN U
e vl= I hemby Ohnn that I ten exempt from the Contractor's License Law for the LOO 1
C"Q fnllowing micon.sec don Inn 5,Hnsinezv and PrnfivJons Code:Any city or eoumr
isF o which reunites v tenon m enns.mc,aper,impmve.demolkii.m repair any xnnatme
is
prior to its issuance.also raptures the applicant for such pemu
do rile a signed statement
a. that he is lictmed monam m the provisions of the Contractor's License Use(Chapter Y loor Area Valuation
(commencing with Section 7(XX)it Division 3 of the Business and Profusions Code)
etch he is exempt menefnnn and be ha,is for the alleged exemption.Any violation
of Gecli.nt 7031,S by unr applicant lar a pco In nuM1jecls the upplic:nn lou civil penalty
(it not more than live hundred dollar.($500). APN Number Occupancy Type
01,us nwncr nfth,popery,of my employee,with wages as their rola compensation.
will do the work,and the structure is not Intended on offered for sale(Sec.7014,
Pnasi uct, red roam„i. ,Cor,The Commmer'x Licene Law doe,nm apply tan Required Inspections
n
or property em loupe or hnpnrvu at such,and who Mtss m n work Intended
r
of mrotgn his own empmyccs, building
that wen mtprovenams are nm mtenae r on 301 — ROUGH PLUMBING
offered
omple ion,the. wt.er builder
me lhave t ur improvementfProv n sold within nor yam of
completion,he"unowe owner rill have the hunlen of proving that he did not build 303 — ROUGH MECHANICAL
in,Pnrvc fret pugnsnu of,de.). - •
304 — ROUGH ELECTRICAL
❑I,mct the
nl me progeny,an,enclusivuly ti Proteing with Iiccmehannra,yors n,
me me pniae 1s«.mace.Rtemm,and Prorex,on,a.ma The comm o., 505 — FINAL ELECTRICAL
License Law docs not apply to..,,.act of ptopcny who huilds or improve, benefit.
and seam contracts lin such praiser,with a canthi l licensel pur,nant m the 507 — FINAL PLUMBING
Cnutnnmr,Liccnm Law.
❑I; exempt under See. ,Hhe tic licehis masoa 508 — FINAL MECHANICAL
Owner Dam
WORKER'S COMPHNSATION DECLARATION
I hereby chich under Peachy of Ilrjany ane of he @dlnwing d,Onnnin I,
O 1 have and will chairman a Cenificam of Consent to uIGin.wre for Worker',
Compensation, as provided lin by Section 3704 of the Labor GWe. for the
perhnmance of the work for which this perotir ix issued.
❑I hove and will muimaio Worker's Compenwtinn Insurance,as required by Section
371X1 of We luh,r ChAc,]or the perlinmmmc nf'tbe work lin which this permit is -
»sea 1nrk�r';Compens�ti,p lnwmnycNo,racers, policy ��a
CI!IYI'II�ICA'IIUN OI/117A NIVI ION-1 ROM WOIt SPRY
CUMPENSNFION INSURANCE
(Thi,section need nm be completed if the permit is Inr one hundred dollars
($IIX)on le".)
I eerily mil in the pcdbmw¢e rel tiro work for which(his permit I,Iswn1,1 -
shall not employ any scrion in any n r m as to they omla
e object the W..kers
CmnPanwtion Laws of California,Damon
Applicant
NO'l'ICE;TO APPLICANT 11.after making this Ccnihcme of Uwntptiun,you should
Z M1¢mne inflect m the Worker',Compcolulinn Pn 1 cal of the LasCuMo
,you not
-
rvlXt a
p mnhwnM1 comply with such provisions or mi,Pem,n,Ball be aaamed evoked. -
f” N CONSTRUCTION LENDING AGENCY
LX ; 1 hereby ufliOr that there is a timed Scen lending agency for the perfanwn«
W ofthc work for which Ihu,pnnit is issued lScc.3097.Civ.C.1
Name
5 Q Lender'.,Addh
� Z IwtndariAJJre,s
U I certify that l have mad this application and scala that the above infonnmion is
LX. [.. a men.I agree u,conlPly with ill airy and unty adinanea,and.oats Inw,relating
O (�J ,huildni.con..mdion,mod herehy anmo mteP 'rntn is on
nlds shy m con,upon
r lite ubovo-n,cnJanaA p tiny fin Inxpec do pltq,nsc,.
lwel asrean, ve.innentndya -keep nanmles the adv orctpemm�against
lin rahJine,.ju igt t.post, es which)tar in any xnY ixrome against wid
U Z City in emscy n flit rat t, his hickperron. �/
^ AP iRS N WILL COMPLY WITH AI ,NO -POINT i
u R, T, 0� Issued by: i Dale
sTn nrAPPrictnvconmae .r ante Re-roofs .
IIA7IARDOUS MAIT,RIAI S DISCLOSURE
Will Else applavul or future traildragoccuMint wom or handle harmardou,material Type of Roof
ax delincd by the Cupcnino Municipal Code,Chnptcr 0.12,and the Health and Safety
Code,Section 25,53200?
Cl ve, 13No All roofs shall be inspected prior to any roofing material being installed.
Wllthc applicant on fawn boddingoccupom utt equipment or device which If a roof is installed without first obtaining an inspection, I agree to remove
mit hmardow air contaminanu as dclined by the Pay Arca Air Quality Management
n•ishien all new materials for inspection. Applicant understands and will comply with
°Yat °N° all non-point source regulations.
1 have ma the h.hdoux t ,atrial,oh cinemcnts under Chapter 6.95 of the
Cubic it Hcuh ,G tiafcty CtWa chi ns:55115.25533 an 25534.I undcmanJ that
it the hnllJing not cun•uly , cnmr,that it is ter raspomibillty to notify the
cey,unl o f w luiat m w us Iw met Prior m isxu,umc 1 a C IiBcutc rel
Signature of Applicant Date
or atntonxm agent ata All roof coverings to be Class •'B"or better
OFFICE