00060014 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUILDINGADDRESS: PERMI ND.
10360 SCENIC BLVD RESIDENTIAL HEATING & A. INC0006001.4
OWNER'S NAMI7.: AI'PLICAI'ION SUB DAnd
BROWN CARL AND KANTER MAR HA 65 CRISTICH LN 06/02/2000
PHONE: SANE1ARY No CONTROL NO,
(408)377-4073
O RCIIII'EC'PHN(11NEER. BUILDING PERMIT INFO
BLDC HLECIITUMB MI CH
ZG= LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affrmnhm 1 am IicenxA under provisionsul Chapter Y(cammenving P
H w tui,hSemion]aMpofDivision 3aftheliusinawndProlJ\sumsCNe,and mylicemc INSTALL AIR CONDITIONER
' in full force and card.
a C C 6 Liter,Class U,p
O U D.m Cnnp:mtar
'y=O ARCHII'ICI'S UECLARAI'ION �{w[j('r/.•']'w(
g 1 andccstand 1uy,hiss shall he used us public,tennis
9 C
'�++ O O LimnaJ Preby affirm
I�
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OWNER-BUILDER DECLARATION
W z—m n 1 hereby a(Rrm ma,I am exempt from the Conlmcu o License ty..forme Q
Z follmsin, t Volo ,niter.and P.[dtiopo Calc;Any tiny nreoumy
Sp four
rcyWrtla cnnit,ncom,flhLnbvq improve,h pci at t tarrepair %dvasvre
K F-pw thath t it...... pr 111': 11 such p 't t esigned.latem u l
(both I Ip ,t thep - Id t t :'I Law tmvpmr9
Icon,Dene ngwin,sem ,n]agnol nn�x�n3tnne Bu'nes,amalrl -.i :Dale) Sq. FL Floor Arca Valuation ,
or that he is exempt therefrom and the basis for the alleged exemption.Any vama,ion
of Section]031.5 by any n,li...I lin a permit wbjec,the applicant m a civil penally
of nm mare roan rhe hundred dollars(scan. APN NumberOccupancy Type,
El 1,as owner of the propeny.ortry cmpluycc%wimwages astheir sole compensation, 35708043. 00
will do the work,and the cancans is out immpdeJ nr uttered bn.sale(sec.7W4,
Hasa .and prurcx.,i„ .Code.The caannmars Licaam Law duel not apply 1a an Re qq Hired Inspections
.th
.of property Who build,or in,prase, he ret,a,and who doe,lith work himell 204 — LINDERFLOOR FRAME
crtmroagh nix own clapdy,t pmmded mat war ie est ,sol are stn immodest a,
e.a for sale.If,haw ,tihic the l have t ser improvement i,,am he did nae year or 301 — ROUGH PLUMBING
completion,fon,he po'c of ale.),will have the M1UNen of proving,hat he did nm buil)nr
nnPra,e rar,ar{,m„eonale.). 303 — ROUGH MECHANICAL
El L as owner of the pmpeny.am cxclu%vely contracting with licensed contractors to 304 — ROUGH ELECTRICAL
I,ports,the,nice,fsw.]uaa,Hpoiac.sad Pror xm,a Conc.)The Cantrnctara
siscruel.awdoa.omapply...",o nenl'p,openywholl„lIdx„r'1manor.roe,ean. 505 — FINAL ELECTRICAL
(tad who eta on,,r.,sate pa,,,whh a eommmoaa)Iiecn,cd ,.r o
are,to m
C,ntmear,uw
ceo tutu. 507 — FINAL PLUMBING
01 am exempt under See. .H re P C for this reawn
508 — FINAL MECHANICAL
ON0`r WORKER'S COMPENSATION DECLARAnON 514 — FINAL PUBLIC WORKS
1 herehy:drm.tinder,snap,of,,,out of the hallowing Jedcouionc '
❑ 1 haw and will v gleam. n Ccrlilicara nt Con.n, h,.self-in,Ure far W..let,
Compensation, a, provided fur by Section 3700 of ,he Labor Cole, far ,he
crlbmmnca of the work for which,his Penni,is issued.
CI 1 has and will maintain Worker',Compensation Insumme,a,required by Section
3700 of,he Labor Code,for,he Wrfrnin:mce of the work for which this permit is
\sued.My Wnrkor',Compcn,a n Insurance tante,and Policy nnmhe,are
Cmricc Pali,No.:
cpin'I McArION OP I?%1!MI'TION FROM WORKERS'
COMPENSATION INSURANCE
(This.action need not be completed if the permit is for one hundred dollar,
1$100)or less)
1 certify 1hm in the perfa nnauce of,he work for which,his permit ie issued,I
,1m:dl
nor'p,lar nay pcsan in any a11n1cr-:o,hat became subject to the Workers
Campepo haul Law,of calnornla.Da,, -
A,phcma
NOl'ICH IO APPLICANT.IL after making this Cenilicnm of Exemption,you should
become suhjen to the Worker's Compensation provision,of the Lalm,Code,you mus,
Q Q fonhw an comply with such provisions or this Permit shall be dccmed revoked.
CONSTRUCT ION LENDING AGENCY •
C > 1 hmehy anirat that diem i,a construction lending agency for the Performance
W of Ilac work,fur which this penml I,i,sted(See.3097,Civ,CJ
QLveder's Manu
Z) Lender's AJJre,..
1 cvmily thin l lime read this aPPlianiun and tam,hat,he show information is
La. E.. correct.1 agree a,comply with all city and county ordinance,and state laws relating '
V h,building construction.and herebyamhorite representatives of,hi,city to enter upon
,he abnvemcmiarial Ppa,dy foram'.inn potr,,.cx.
We)agree to save,iadenmily and keep harmle,me City of Cuperino ugaina
alphtica,jadgmavl.,cost,and capanscs which may is any way accnte agaarnl said
V Z City in eon tsp cnoe of the grmling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
Signata.of Ap,licanUCommctof Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the ap,lican,in,future nodding m,,a,.,,,ore or handle hamrdom n,uterial Type of Roof
ax defined by the CUPWhrO Manieipnl Cade.Chapter 9,12,need d.Health and Snfcty
Code.Stenon 25532x0?
[3Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will me.,,Iterm ,,hope.bnildingoccupan,use equipment or device.which If a roof is installed without first obtaining an inspection; 1 agree to remove
ams hvaNnus air contaminants a,defined by the Bay Area Air Quality Management
nxmcn all new materials for inspection. Applicant understands and will comply with
C CJ Nu all non-point Source regulations.
have m:W rhe hm.Urdous retrials nquinmen,s under Chapter 695 of the
lorn'u1 Ie111ha,Sufmy Code.Smllnnx 25505.25531 and 25534. undctrol:umA Ihal
d,hc nuilAing dxs nm correctly h'nvealcnanl,that itnlay re.pum,iMlity t nolay the
irruption of the requirements which Imo„he mel prior rat is,uanee of a Cenircae of
Occupancy.
Signature of Applicant Date
Owner or mutin,ed agent Date All roof coverings to be Class B” or better