02110111 (2) CITY OF CUPEKI'INO
BUILDING DIVISION PERMIT CONTRACTORJNFORMATION.�
RulgD@6ALI?4Rl4vIADERA DR A PERFECT CLIMATE PERMI'rN02110111
owtTAMNAEGATTO 10570 S DEANZA BLVD APPLICATIPJ1)0115TY2002
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IONF: 408 861-9545 SANITARY NO. CONTROL NO.
ARCIU ECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
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k100 LICENSED CONTRACTOR'S DECLARATION
zr I hereby altirm that l am licensed under provisinnc of Chapter 9(commencing Job Description
rn<i with SeellunTXXI)of Division 3 of Ne Business and professions Core.and my license is NEW A/C
FON On lull fans and cffc ^
20 K Llcrove Clues �OaO
to Lica
ON—p Date_t Contrazun
F—L�pOy RCHFiTcTSDECI.ARATI N
�iC rL� I understand my plant shallbe used as public records
oau
u�LLO� Liccned 11 1cssiumal
F'— OWNER-BUILDER DECIARA'I'ION
Sur I hereby allirm that I am exempt from the Contractor's License Law for the $4 964
tai p O following reason.(Section 703 1.5,Business and Professions Cnde:Any city of county
a.
%'m which emotes a permit rel construct,alter,improve,demolish,ser repair any.sloomre
ar—w motions issuance.also requires the applicant for such p:rmino file a signed stmemem
Fie that he it licensed pursuant to the provisions of the Contrac'tor's License Law(Chapler 9 3S16Bt5I0&BA@0 Valuation
M L a (commencing with Section 70CM)of Division 3 of the Buri nest and Professions Code)it
i 3$ 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 to a civil penalty of JUAFLNN Occupancy Type
not morethan fin hundred douan($500). 304 - ROUGH ELECTRICAL
❑ Losow orof the pesumat remyemntendesw offered
for
(Sesc704,LBsiness
will Jo she wall.and the swnum isnot intended or offered for salt(Sec.70W,Business 5E)5 F1
and Professions Cods:no Contristmea License Law does not apply to as owner of 508 - FINALrttl ons
property who builds ser improves mere.,and who does such work himself or through his
own employees.provided that well improvemems are not intended or offered for We.IL
however,the building or improvement is sold within one ysar of completion,the owner-
builder will bare the burden of prising mat he did not build or improve for purpose of
sale.).
I,as manic of the property.am exclusively contracting with licensed contractors m
construct Ne project(Sec 71Na,Busines and Professions Code:)The Contractor's Li.
cense Law does not apply to an owner of property who holds or improves Hereon,and
who contracts for such projects with a contraclm(s)licensed pursuant to the Contractor's
License law.
0 1 am exempt under Sec. B&P C for this maxon
Owner Dam �E� 0 5 2002
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury one of the following declarations: p�/�
I have and will maintain a Cenificam of Consent to self-insure for Worker's Compen- B JLDJt4 A
ration.as provided for by Sectio 370(1 of me Labor Curie,for the performance of the IV v
r for which this permit is issued.
w I hats and will maintain Worker's Compensation Insurance,as required by Section
p of the Labor Code,for the performance of the work for which this permit is issued.
orkc' oroppLnsau Insurel�/ge carrier and Pol icy nundirr am
Cartier: 7fL- �CA Policy Nn: IS -
Llll -s
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the hermit is Rnonc hundred dollars($hi)
or Icss.)
1 acnify that in the Performance of the work Int which this permit is iatued,I shall not
employ any Person in any manner so ax m become subject to the Workeri Compensation
Lawx of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject m the Wnrkcis Compensation provisions of the labor Code,you must
0z f thwith comply with such provisions or this permitshall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
rI hereby affirm that there is a construction lending agency[or he performance of
the work for which this permit is issued(Set.3097,Ci,C.)
0 Lender's Name /y
z
U
Lar
der's Address
0 1 certify that 1 have read this application unJ sone that the above information is
U.(.. council.l agrec to comply with all city and county ordinances and sum laws totaling it)
O V building construction.and hereby motion reprarmatives of this city to enter upon the
above-mentioned property for inspection purposes.
Fa es ptgnrs,rove,indemnify and keep harmless the yite of Cu mrn,s against
y liabilitics,judgmcnls,ensu and capnscs which may in any way accme against said City
V Z in consequence of me granting of this permit.
.� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Ahplicac
HAZARDOUS
[)are
MATE RIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle M1a mous material
as defined by the Cupertino X,.l Critic,Chapter 9.12,and the Health and Safety
Codc.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yeswill mea ream madding Occupant see equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
rep gs pan quipmen
mot ha,amoas air conla ofairy tv ydewed by the Bay Area Air Dearly Management all new materials for inspection.
District'!
❑Yes
I have remUh �douvmamrial.t reyuiremeu under CM1apmrfi95ulthcCnlibn-
menHcalth&Salm 25515.25533md255UAur& us addtmifthebuildmg
the not current thait itmY.,,Onxbi1i,y m mr0ly the Occupant of the
requitemcnswlipriorlmixwanaofacemm:atem� wP cr. _ Signature of Applicant Dale
Own,' mm rid agent I D e �- All roof coverings to be Class "B" or better