03030127 (2) CITY OF CUPERTINO
Buauwc 'IVIs1oN PPRMIT kCONTRA C l UR INFO�RIV A roI0„N r
BUILDINGADDRESS: - PERMITNO.
A B S HEATING & AIR COND
GWNE 334 SHAMROCK DR-
Hsi
R' PERMITS
NQ�IRTZANQ _14 SANITARY 0 OL NO.
(408) 238=.7178`
RCHITECT`ENOINEER: _ BUIIDINO PESIM ff INFO
BLDG ELECT Is MECH '
Brs06 LICENSED CONTRACTOR'S DECLARATION O O O O
1 hereby affirm that I am Ilamcd under previsions Of Chapter 9(commencing Job Description
with Section 7070)of Division 3 of the Busincseand Promashms Code.and my license is
In run force and effect
14 a m, A u.a O REPLACE FURNACE & A/C FINALeo
Dere _CroS DEC -
ARCNliWuse DECLARATION
�i IundcmenJ my plemshallWumdupuhlic rccnnls' Y MAR 2 A 2003
3� Licensed Pmfesioml MR tG J
OWNEm axe AER DECLARATION
” 13 I hereby mem t(Onn Inn I I.S.exempt from the cnntns Co License Law for the _ BUILDING
13 following mann. comm(Section]03 ontinr.alias and Improve.
deslom Cale:Any city or aunty -
$ whim requires•permit re cnwrvet,a@a Improve,de Permit
t m repair any time man.,
1- that Isar nluissumc0.alaoeguiresothe the inions of far such Contrarmilm.le.Lawdmmment
qq < (c mine RccnuJ puruanuntha previsions of the Contractor'.License Law Code)or
SQ.Ft.Floor Area V I IOn
tcot he
exempthscnfon mm and of basis for
tithe
eged exemption.
Anand y
Cndc)Or 1�`u"
36 Nn io Is exempt Neufmm and the brie for bj alleged eumant ED Any l pennon of -
nenlon'IDolivehundreddolla31.5 by anyapplicant,rs(M).itubjoutheapplicantu•civilpemltyof ep7�tbra1Igt1le{.er Occupancy Type
net mon Wnfiw hundred dollars(5500). . 31bs4 tfV�aF �� p y yp
0 1.u owner of the property,or my employers with wages as their sale compensation, '
will do Us,wmiEmd the aWclum is not intended or.B[nd I...e(Sec.]M4,BWinesa 01 - ROUGH
and Professions Code:The Cnnrracces License Law docs not apply m an oer wnof 3I&IltiHbHNQctions
Property who bulld.orimprows thcame,end whodoesauchwork hlmulfor through his .303 - ROUGH MECHANICAL
own employees,provided that such improvements are not intended oroReed for"le.If,
however.the building or improvement is old within aro year of completion,the owner. 304 ROUGH ELECTRICAL
Wilder w0l Nw the burden or proving that he did nor Wild or Improve for purpose of 505 - FINAL -ELECTRICAL
sic.).
❑Las owner of the popeny,am exclusively contracting with Imented contractors to -507 FINAL PLUMBING '
construct the project(Sec.7044,Business and Professions Code:)The Contraem8 U. - 508 - FINAL MECHANICAL
ansa Law does not apply It an owmr of property who Wilda or improves ucmen.and
,who contracts for such projects with a eanmetor(q licensed pursuant to the Comruloes
License Law. -
❑lamexemplunderSea ,B At P C for this won
Owner Data -
WORKERS COMPENSATIONDECLARATION
I Nreby afnrse under penalty or perjury Otani the following dulanll...
Nat advent mainulna Cesirieste ofcomma loself-Imum forworkehcompen.
on,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is Issued. - f
I
❑1 have and will mainuin Workers Compensation Insurance,as required by Section
3700of the labor Code,fat the perfmmanee of the work for which this permit a issued. _
My Waikato Comppmandon lneunnacmlerod Polly n beA / I ,.
Cartier z �j�l{� Polity No,: t'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(Thissec[Inn need not W oomph mil if the pconrlt is foronehundmd dollars(5100)
or leas.) - -
-' I cenify that In the perrancome of see work for which this permit is Issued,I shall not -'— ----- - - -• - - -- - �- - - - - -
employanyperoninaiyalmoeranumbecomesubjectntheWorken'Cumpemetian - ..
Laws of California.Dam
Applicant ..
NOTICE TO APPLICANT:If.after making NU Cenllieste of Exemption.you should
Income subject in the Workers Compensation provisions of the Labor Crude,ynu muse
O fanhwiihcomply with such previsions or this permitshallMdecreed ranked.
CONSTRUCTION LENDING AGENCY
F l hcrobjeafflam that dartusued(m.3D97.nding gena for the lcrfnmana of
CG site war:for which this permit h issued(Sm.3097,Civ.C.) .. ..
Wry Q Leners WE -
=z Lender` Address
U Q 1 certify that l haw mad this application and Nm that the aWw informniun u -
fL P career.I Ague to comply with all city and county ordinances and sure laws elating m
p U building convection,and heathy othorlu representatives Of this city to enter upon the 3)14
W
.hon-mentioned property for inspection purposes. -
gy (we)agree m use.indemnify and kap harmless the City of C9PcninO Against
Uh Ilabllitmajudgmenq expenses which and expewhich may in any my accrue against said City
U
"J In consequence ofthe granting of[his permit.
F7 SkRC ACJ r UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sQQIRCtGjG�Q.CONS.
sP/kJI Q11I 1 r124-O3 Re-roofs .
Signature of App eent/Contr..to, Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will uc ipplicam or future Wilding Occupant slam or Nndlc hsudous material -
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely -
ctdc,5rstion25532(a)] 1 ) All roofs shall be inspected prior to any roofing material being installed.
❑Yes a
Will the apple=[or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
il.,dnua sir memmins Wc deOneJ by sec Bay Area Air Quality Management all new materials for inspection.
fact . -
I have mW see NuNnusmamnaH requirements under Chapter 6.95of the Califon -
iliaHcaluASefclyCade,Saduns2.5505,25533md25534,1undcmandumiftim Wilding -
�J an I currently haw a mount.reel It h my usponsibllhy m nobly the amuprt ofuc '
in,,9�is It must Wmet MIDI miuumceofaccniOateofOccuaney. Signature of Applicant Date
'roraut�t `3 �d7 All roof coverings to be Class "B"or better
Owner or eulhonvtJ agent Date g