01040071 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT No,
19937 PEAR TREE LR CONDITIONED AIR VJL7171
OWNER'S NA>IH. APPLICATION SUB DATE
/2001
GoHONE: SANITARY NO. CONTROL NO.
0 9 0 ARCHI I CCUENGINFER: BUILDING PERMIT INFO
kL" ❑ BLIH'i I.LI.CT YLUNIf MCCII
UW ,_ 1_I 1=1 1=1
ftr-N LICHNSED CON'IRACIOR'S OECIARATION Job Description
CO m 1 hereby affirm that I ant licensed under prnveiaro ul Chapter 9lemmnencing
w 1-w 1rhSttlian7(XX)I(it Division J of the litixi nessand Profession,Cala and my license
is in full tone and effect.
uecn,ecla„ I'ie.w FURNACE CHANGEOUT, 3 TON RC ADD ON,
P
,U Dan Cmnnetm
w sa.V ARCun'Ecr•s DIICLnennoN ELECTRICAL.
1 and entunduly plan,.hall he used as pant me...d,
5
Licensed Professional
that I o exempt
IIECe Contractor',
=N I neem).(rico that 11, cmmpt s an the Contntelor Limine Law for the
1—z a fallowing musnn.(Snaiun 70?L5,Busino>and I'mles,ians Code:Any city ser cranny
S s 0 which...puns a 1avn.it ,,consmmL:dmr,improve.detnolnh,ar mpair it,structure
re
i3= pdamo its issuance.also requires the applicant for such pennluo life a signed statement
N.I ne is lieenxed ppl.memmn.e pea.......,of iha Camraelars License Law Whales,9 Sy. Ft. Floor Area Valuation
Ieommencing with Smtian 7000)of Division J of the Business and Profession,Code)
or Ihm he is e,cmpl Iherd'ront and the basis for Tho alleged oxmnpdon.Any violation
of Section 70 I S by any applicant for a pemeit subjects the applicant to a civil penalty
aIno,nmrethim five hundred dollars19mXp. APN Number Occupanc 1�8
01,as owner of the property,of em employers with wages as their soleennpenm(tan,
will du rhe wort.,and the sm,lum i,nor intended or offered far.sale(Sec.7194,
Business and Professions Code:The Contractor's License Law does not apply to all 3163008l§ef�6ed Inspections -
owner`uf ptaperty Will)builds or lope.e,There and who does such work NfirwIf
or Through his own employees.providedthat such inipsocanats am not amended car
ot't'ered for sale.11,however,the building or oullao.n crit is sold within line year of
ompletion.the owner-builder will have the burden ofpmving that he did not build or 301 — ROUGH PLUMBING
improve for pram,ol'-in.),
❑I.as owner of the unitary,amexclusively contracting with licensedcnnnoulor,a. 303 — ROUGH MECHANICAL_
Liconstrict nee project(Sec.7094,Ba, x and Proessi a Code:)The Cantmnor, 304 — ROUGH ELECTRICAL
cense Law docs not apply to m owns,of property he huild m improve,memor,
c.all sella c..afrael, lar stun projects with a concitetml,)licensed pr.ru:mt ,,the 505 — FINAL ELECTRICAL
amrumr',Lwease Law.
❑Iam.,.,nptide,Ser. B&11CI teaateeson 507 — FINAL PLUMBING
Owner Dane 508 — FINAL MECHANICAL_
WORKER'S COMPIiNSATION DECLARATION
1 hrnchy affirm ndpe
uer nalty of perjury one of the following declarations:
7 I hile and will . rinear u Certificate of Consent to,self-inwm lisp Worker's
Compemallan. as provided Lor by Section 471X1 of the Lues Code, for the
,,donna....of do work far wlaid,This pmol(I,island
❑1 base sad will aarnint,tin Worker,Con,a,madon lv.m:ince.c,expired by Section F I ISI ALE D
3700 of the Lathan Cade,for the Icrfrrmanm of the work far which the. .,it is
issued.My Worker,Compcnsuire tolerates,tamer and policy nunhr are: MAY 2 d y 2001
Camey Policy No.:
CERTIFICATION OF EXENIM[ON FROM WORKERS'
COSIPHNSATION INSURANCE
(Thi.s,evion need not he completed if the permit is liar one hundred dollars BUILDING
6100)or Iaa.)
1 certify that m the alio nonce of the work I'ur which his per nil i,useed.I _
,shall not employ any versusin any manner m as to a
become subject ,the Workers
Compensation Luws of Caluiania.D.m
Applicant
NOi ICH O APPLICANT,II; for,making this Certificate of Exemption,you.should
na'anm subjrcl to the Workers Compensation provisions of the labar Code,you must
Z
0 forthwith comply with.such previsions or this pemat shall be,deemed invoked
rn CONSTRUCTION LENDING AGENCY
Lr I haeny Which
this
unit is oemd!(See lending vgancy far the perfnnnnnec
of Ne wad,fur which This pemeit is iswN(Sec.JI})].Co.C.)
� C Lender's Nome
�D Z lender:Address
C.) 0 1 rectify that I have read this application and state that the alan'c information is
Li. correct.I agree to comply with all city and county ordinances and sane lawn relating
Q CF.I obuilding an.wmction.and herebyauNuriee representatives ofthe.city to enter upon
is the uM,ve-mentioned pi for inspection purposes.
[rL (We)agree 0lave.indenmify'end keep harmless the City of Cupcnino agmnw
N liabilities,judgments.costs and expenses which any in any way.,,.c.guns(slid
U Z City II ,cpec of fire grunting of his I alnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHAM NON-POINT Issued by: Date '
SOURCC RIiGULAI'IONS. y'
Signamreaf ApplimaOCammeoer D.rte Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam or farm Wilding uhupmn son nr handle b:vadom.martial Type of Roof
o dctineJ ny the Cr gxn inn M1lunminal Code Chapter 9.12,and the Health and Safety
Calle.Similar 25534(ap
oyes ❑No All roofs shall be inspected prior to any roofing material being installed.
will he aplliecom if been,I Ifirga...mam now equip.ncut at devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
mm broacher,che,air coma ninanu as dManagement...
by the Bay Area Air Quality Manageent
�a.cu..C' all new materials for inspection. Applicant understands and will comply with
O Yes ON., all non-point source regulations.
I ha,c read the htaardrne nunerials requiremcnm under Chapter 6,95 of the
California Ileuhh&Safety Cede Sections 25505,25533 all 255 14.1 underaund deft
if the building does net currently have a tenant.that it is my responsibility to notify the
acculvot of the requirement,which must he incl prior to issuance of a Certificate of
U¢uparey.
Signature of Applicant Date
Owner at antharvcd allem Irate All roof coverings to be Class "B"or better
OFFICE