02110050 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT °CONTRACTOR3'INFORMATION:
BU&08M)&ENORTHRIDGE SQ VALLEY HEATING & COOLING PERMIT No.2110050
owp{d'9A`RdSIN VICTOR K 1171 N 4 TH ST APPI.ICATpl1sPW-2002
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IIONE: 4- 290 SANITARY NO. CON rROL NO.
ARC]I ITECfdiNGI NEER: BUILDING PERMIT INFO
RLUG ELIiCI' PLUMB MECH
0
Juno LICENSED CONTRACTOR'S UECIARAI'[ON
u p 1 hcrchy al him that 1 um licensed under provisions of Chapter 9(commencing Job Description
won See, 7(XXnmDivmion 3rd me Bashess and Pror...J�ya,C d rthmenw i. FURNACE & A/C
in DIB fimm an cf 1. � �JO
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oz DI i O d cnmennr L � B�f/X"9 LS.I�
ARCIII Cf:S D:' RATION
"„aW NOV 1 4 2002
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ad a. ; L'1cenn fulfosinnal s
Oj OWNER-BUILIIER DECLARATION c
<£1 thereby oflifm that 1 am exempt from The Contractor Lleenm Law for the y 000
no following mann.(Section 703.5,Business and Pn iessions Code:Any city or ctenty UfLD9� (a
n 2 which requires a Permit to construct,alter,improve,demolish.(it repair any strure
ctu
zy prior to its issuance.also requires the applicant for such Permit to file a signed statement 39y6 B16IQ�l�C Afk@ Valuation
yy a mut he is lice Bud pumounno the pnsvisiunsof me Contmewr's License l.aw(Chaper9
(commencing with Section 7(XX))of Division 3 of the Business and Professions Code)Or
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 Be applicant to a civil penalty of J UXPNN Occupancy Type
not mom than r hundred dollars S500). 303 - ROUGH MECHANICAL
❑I,as owner of the pmpedy,or my employees with wages as their sale compensator. 3 04 GH
will do the work,and the structure is not amended m offered for sale(Sec.704a,Business
and Professions Code:the Contracmr's License docs nm apply to an owner of 5 0 5 - F I NAL �hOn$
property who builds or improves thereon,and who dues such work himself or through his
employees,provided that such improvements arc notinended orofmred formle.If, 507 — FINAL PLUMBING
however.the building or improvement is sold within one year of completion.the owner- 508 - FINAL MECHANICAL
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of the property,am exclusively eunnucting with licensed contractors ur
construct the project(Sec.7044.Business and professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and.
who contract for such projects with a cmemetnr(s)licensed pursuant o the Contractor's
Lice
n.m Law.
❑1 am esent antler See .B 6 PC(nr this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury one of the following declsrminns:
1 have and will maintain a CcniOcae of Consent a self insure for Worler sCompcm
cation,as provided for by Section 371X1 of the Lehr Code.for the performance of the
work for which Nis permil is issued,
❑1 have and will maintain Worker's Compensation Insurance,ses required by Section
371X)of the Iahnr Code.for the performance of ran work for which Nis Permit is issued.
My Wor Ct in Ins cc carrier anJ Policy number rete: 0 65f),?
GGtr(/
Canis: s/ rt o Poli w 1 � ✓ O
ERTIFICATE OFEXEMPI'JUN WORKERS'
COMPENSATION INSURANCE
(This tycoon need not be eturpleed if the sonnit is Inform hundred dollars nRXB
,it Icss.)
I certify that in the perfnrmance of the work for which this permit is issued,I shall not
employ any fiction in any manner io as on NAd a xubjccuo the Workcri Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICAW:If,after making this Cenillcae of Exemption,you should
become subject to the Worker's Compensation provisions of the UNe Cook.you mast
L7Z forthwith comply wiNsuch provisions or this permi l shall he deemed revoked
z O CONSTRUCTION LENDING AGENCY
[-. I I hereby alarm that there is a cnnstronion lending agency lou the lerforman c of
ai 7 the work for which this permit is issued(See.AMA.Civ,C.)
LIQ Lenders Name
l3, I uder's Address
U O 1 certify that 1 have read this application and sure that the above information is
I. F correct.l agree to comply with all city and county ordinances and sum laws relating it)
0 building construction,and hcrchy uuthonre mpresenmums of oris city to enter upon the
r n7 aMwc-mentioned property for inspection purposes.
(We)agree a save,indemnify and keep harmless the City of Cupertino against
FF-t N liabilitics.judgmcnls,cuatsanJ csNnscswti'btu yin any way accmc against said City
U Z in eonaequeaceof the grumingnfthisper t.
t-' API'LI AN UNDERSTAND ANO IL COMPLY WHIZ ALL NON IN' ]$$UCd by: Date
SO C ,GULATIONS.
Re-roofs
rm of Applicant/Contractor tic
I1 A'],ARDOUS MATHRIALS DISCLOSUR Type of Roof
Will the apPlicam nr fmure building Occupant score or handle tharallous material
a defined by the CuPeni'rn Municipal Cndc,Chapter 9.12,amt the Health and Safety
code,senmesr 15532(ayr /NO All roofs shall be inspected prior to any roofing material being installed.
�V7
Will thea licant or future buildin ca t use e uientordevices whim If a roof is installed without first obtaining an inspection, ]agree to remove
PP g+e pan qpm
Dmit hamol air csmmmiwnm dcfred by the Bay Arca Air Quality Management all new materials for inspection.
u1rin!
❑Yea Nu
1 have read the hasainous materials equircments under Chaper6.95 of the Califor.
nia hell ASafety C,k,Sccuona25505.25533and25534.1undersmdNut Ifthc building
does nm,mmoily have Jenunt,thu resryn¢inilily ro nobly(be 'cup' 1 nl the
1e -e ntswh,eh rtbmmel rtl�air'aneenraceriteMeifa par' L Signature of Applicant Date
r alrmmked ager All roof coverings to be Class"B” or better