02050086 (2) OF
CI BUILD NG DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BI(IITI '71"RE CLELLAN RD A & H HEATING PERMIT NO, 02050086
T 770 CHESTNUT ST
",PHONE'... (408) 279-0722 SANITARY NO, CONTROL NO.
O OARCHI'rETER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
S N LICENSED CONTRACTOR'S DECLARATION b
I hereby affmadot l am licensed under provisions of Chapter 9(commencing 2 TON A/C ADD O V�f {p`�g0 VOLT CIRCUIT
C; with Section 7")of Division 3ofine Bysineas arta Roressions code..nd my ran.
sin full r m and n. J[' p
a LiccnscC Lic.M f-f' FINALE®
'OaU Det _cam-_/y- Conl cmr 1�
j 3 n G t— A TELT'S,yR{tgLAR ION
1 a O 1 understand my plan,shall be asteria,as,
recoNs
' a JUN 17 2002
3 a.ca O LkcmcJ Professional
' LAIUo[ON
n m Oat lam exempt
To DB Ce Cortrwum
t I hereby.them that 1 1. cB usin from the CosionsC s License Law for the yS 2 S O O
y
following Permit
7WL5.Busite,impr Professions Code Any cry or county BUILDING
whichrequires Perm t r c n tram ¢ p demMrsh o repair any structure
�st3
that he 9lcensed purvartruto the p I s ofthe Contortion's License Law IChs,ur9 ..3.�1)B,Ct8n:A lea-,� x T �Pt Valuation
Ic aridng with Sect 700(o fD 'si 3 fthe Business and Professions Cade) ✓ , j I\.-s♦ 1 s,!', 5.",l • ti\ •s '4 t L• -
or that be to exempt berefrom and the basis for rite allege((aemiamil Any violation
-of Section 7031.5 by any ap,,limut for a permit subjects the applicant to a civil penalty
of not more than love hundred dollars(s50% 204APNIUNDERFL00R F E..c!,,r', Occupancy Type
Dl.as owner of property.or my employees with wages as their sole compensation. 301 — ROUGH PLUMBIN
will do the work,and the structure isnotintended or offered for sate(See.70,PL - 303P.. .I:
Business and Professions Code:The Contractor's License Law does not apply to an - GH MFS d e[ionS "
owner of property Who Wilds or improves thrrcon,and who does such work himself 3 0 4 - ROUGH ELE TRI CAL
or through h s awn .employees p 'd d th t ch' p .mare of tended or
offered rd,selef l however,the building or nrroement s sold w thin one rear of S05- _ FINAL" ELECTRICAL-
offered CAli;
'lompletr n,the ownemW ildw will have the burden of proving that he did not Wild or •� •,
improve for pnrpr se of sale.). S 0 7 - FINAL PLUMBING
iiu9 r,wo8 ofthe prope6y'at xria,melr cnnimuimq with licensed cd arto6m 508 ---FINAL-MECHANICAL- _ ;,i;;.;,;•,. ;'ries -
conammlheprojepr(Sm.7oaLBosmess and Pmfesmo,Code.ITire Commistirs 514 - FINAL PUBLIC WORKS.,
Licari raW docs not apply to an owner of property who builds cr improves thereon,
.. ]. ._dudwho contracts incruch.protects witha.contranorts)licensed prouamt.10.1he
Communes License Law.
❑lam exempt under Sec. .B&P C for this reason
own2rr" : ,,. .nate. ..
WORKER'S COMPENSATION DECLARATION
+ •s"' .I hereby affimn under penalty of f{erjury,one of the following declarations.
❑ 1 have and will'mainmin'a Ceni icate'of Consent to self-insure for worker's
f�YCompensation. as Provided lar by Section 37W of the Labor Code, for the
performance of the work for which this permit is issued.
❑1 have and will nulnr aln Worker's Compensmion Insurance,as required by Section
3700 o1 he'Labir Cede,for the perlhnnance of the w&k'fmr which this permit is
iss d,My Worker s Compensat on Insurance cancer and Policy number are:
et ri'i.•
NfglnZ65�7
CATONGFEXEW1stFAOMWORKRS '�
COMPENSATION INSURANCE
............ _....
1E100)or
fle union need nm he completed tf the permit is far one hutdtW dollars - ''"
or
lnsJ
1 carfify'd t io person
f the rk fi r a h tb"pe iix*-auiJ"1 -
Con not employ Laws
pe n In any mann r in,ai to Wmme stabler to the workcra
compensotian Iaws of Califdmie:Data
Appliewil -_----- --
_
NOTICE TO APPLICANT:Ipafter making this Certificate of Exemption.you should
Fc oure subject to the Worker a Compensation provisions of the Labor Cade,you must
Q O fdnhwith comply with such provisions or this permit shall be deemed revoked.
Z _ .. .. -. . . . ._ _... _-.._-. .... .._...
P.r`a/� t t - '-" ";CONSTRUCTION LENDING AGENCY "'
> ';' 1 hemby,affirin Woe there is a construction lending agency for the performana
of the okf which pant'.issued c 30970 C) '
tti _..: ........ . .... . .. . . ..
Lend N - - - .
.7 Ixnticrs Add a-: ). t ry
V-Q 1 certify,that 1 have read thio applicmion and stat a tha dra above information is
C.0 cored.1 g construction,
on to comply with all city county Ordinances and shite laws relating '4
Q',z, mbuildiI agort Cmar,andhcrcbyityand erepreodinancntatives sfndthis tcity e to laws re upon
r �] the above-mentioned property for inspection purposes. .
:F� Q. (Wc)agree to stair.indemnify and keep harmlessthe City of Cuscrinb against
Vl liabilities,sequence costs and ingenue which may in any way accrve against said ^ I
U uZa City in consequence j.d, sec of the emoting of this which
_ - APPLICANT UNDERSTANDS A ' WILL COMPLY WITH ALL'NP-POINT' Issued DdIC
5 UR'ERF.Gl11:AT10Ns'. : �TYI Y•
Signa o ApplicanJCommaoi',`,'_" -" ,Parc t' t Re-roofs
'HA.Rosd fI MATI RIALI DISCLOSU E ..
Viii thapplicant f t building p t sum or n dl hrzww1 mmcmal Type of Roof_.
as"def ed by the Cupertino Municipal.Code.Chapter 912 and theHealth and Safety , f y 1
Cdde S t 2553?ra)s ` -I r r, j t. .
I `
' �Y°' •t' 1
All roofs shall be inspected prior to.any roof ng-materia]being installed._ ..
WD the applicant ortfuture Wilding occupant use equipment or daces which If a roof is installed without first obtaining an inspection; I agree'to'remove
cath do nt n t defined b)theBay Arc,A Quality Management
Dist t all new materials for inspection. Applicant understands and will comply with
ff DY r P*� , all non-point source regulations.• , ., .. -
Y 1 have read The hazrNous marcrod,iegmrements under Chapter 6,95 of he
Caliromii Healih&'Safety'Code.Seniors 25505,25533 and 25534.I understand that _
-i f the building does not currently have a tenant,that it is my responsibility m notify the -
1 u'sm of the require is which t t m mm pricer to Is.once of a Certificate'of
_ 1.
`• e Signature of Applicant
O cu y.
Date
All roof coverings to be Class "B" or better
ScatDate.. g
,• •a:
OFFICE .
,•. -.•.- .. . - - .