01100118 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21423 SHANNON CT A PERFECT CLIMATE 01100118
OWNER'S NAME: APPLICATIONS BDATE
SCHMIDT ARTHUR J AND CHARLOTTE 10570 S DEANZA BLVD 10/23/2001
PHONE (408) 861-9545 SANITARY NO, CONTROL NO.
q Q z0 ARCHITEC"VENGINEER: BUILDING PERMIT INTO
EL"to❑ BLDG ELECT PLUMB idECH
LICENSED CONTRACTOR'S DECLARATION
H= I bemb rpmm that I am licensed ander s ofcha ter 9(commencin Job Description
pro"isi°° ll FURNACE CHANGE OUT.
tea
is
:
tion70B0)of Division 3 of the Business and Professions Cud•,and my license
y izforce end
Sou Lic.x
°s Contractor f a 0 Yn s A HIThul S DECLARAT N
e understand my plat shall be used as public records
5 i p Licensed Professional
OWNER"4- BUILDER DECLARATION
affairs I hereby afRrtthat 1 em exempt from the Contmnor's License Law for the
followea
3 a which requires
e mason. ernottt ]onstr Business and improve.
demolish.
e oli Code:Any city stcounty $3108
Him which ,, t c Ise sot construct. p d al Irepair' y suucn u
prion t. .- Is y d pprc t f h pc set fiesignedw(Chapter
Cha o .- - - . ._.__ ... _. _ _ —._ .- __
°• - thathe is licensed pursuant r'7thi"pro Iston of the Contractor al s lv (Chaps r9 ,��,a,�k,,,� e
or th mg with Section]ai and the
basis
the Ill ripen and,i PmfA y ns Cod) -(;;` ! ,3 VSilk1/`D'C�V�aT�a ? ,-�'I(�Y" Valuation
or that io is 31.5 b tang applicant
and for basis for the subjects
the aemant to Any violation
of Section than v any hundred
o ll fora permit subjau the applicant to a evil prnnlry
,or not mare man five huodaa corers lESW). 301ApN 4tltnhfCSH PLUMBIN ' Occupancy Type
❑I;as wnernnneprop=ry.arnry=mployaewithwagesaaneiranlecompnsati°n, 303 A
ROUGH MECHANI L
will'Business
the work,and the straCode:
is intended'aLi en a eredLaw does
sale(See.row.- 3 04 - ROUGH EI1iWCjuWiad Pii§ ctions i' ;'.'t ` IF
'will d is end Prowork,
and the
Cd=:The is n t s License Law does not apply man
owturof,.,Ay Who Guilds or impmvestheron,end who ducs such weak himself 505 - FINAL ELECTRICAL
or through his own employees,provided that such improvements am not infuri ed or _ _
of fired for sale.H,however,the wilding or improvement is sold wimm ane year of 507 - FINAL PLUMBING
improve fur the omofwilener will have m=burden of proving that he did not baud or 508 - FINAL MECHANICAL
improve the owner-Wilder
p.. ❑1:as mer da, of the property,am Bul..exclusivelyad
with CWc:)The C.,...to- - - - - - - - - - - - -- CI. 'c'%"1:'• r.
omwm the oe,Out
(Site ,. Business and erufemions Code:)The Cuntracmr's
License law dere ma apply to on owl,of property who Wilds seimproves t to dre
and h tracts fors r. p Tau with t tors)licensed p rsuent to dte
Cont t e L rue Ww.
0 pt under Sec: t .B&PCfor his reasonlrll / 0
Owtt D
Date 2
-WORKER'S COMPENSATION DECLARATION O
1 hcrabY affirm under,a lty of perj,ir,one of the following declamations: ` O
❑ I have and.0r a tiamin a Cenificom of Consent to wit-imma for Work°r's /
Compensation, as provided for by Section 37W of the Labor Code, for the
Performance of the work fur which this permit is issued..
- ❑1 have rod will mainmin Worker's Crmpcnsmion Imuance,as required by Sauon
371 the Is W,Code,forlhe pbpfommnsc of the work for which this Perrot is
I
d My�W^orkte,',Compensation Insurance and Policy number
ram: ,
ams crJ7�lt s �POI CY Nn �U {{.
CERTIFICATION OF-EXEMPTION FROM.WORKERS!s, I,(1'1 ,�s )Sea r.�4i t�.�pYY j ':((1. -i l at.
"'-
COMP ENSATION'INSURANCE
' •jTTis uiiioI rottednorbe compleicd if th°permit is for Otte hundred dollen ` „' "� " ' " yj"tti�a •' �'
Ic rfy that in thit effamnarEeof th kf hch thi,aimril ii issued;) �- - - - t ,t ,((T,Ipt ' _
-shall not employ any Person in any manner so m
as to beco = bject to.the Workers r
pp - '
Applican1.t Com tion laws of Celifomie.Date
NOTICE TO APPLICANT.If,aper making this Certificate of Exemption,you should
Wcimae subject to the Worker's Compensation providoris of the labor Code,yin mor
O forthwid(comply`vi such provisions or this permit shell be deemed rivalled. '
E`4 I• 'I ' " I CON STRUCI'IONLENDING AGENCY' "
-' 1 hereby affirm that there is a'consiiuction lending agency for the,performance -
. W of the work7or which this Perrin is issued ISee J09].Civ.C)
Lender's Name
Lender',Addreu
t
t:7 .T certify that 1 have read this application and state that the above information is
+W imrect.I agree to comply wish all city and cnumy ordinances and state laws relining
�Oto building conswetion.and fiembyauthorizeiepresentativesofthis city tocaterupon
rt the abuvemendoned property for inspection purposes..,, _
^;C. (We)igme in save,indemnify and kap hornless the City of Cupcniro against
Vl liabilities,judgmams,costs and asperses which may in any wayaccrueagairut mid
V"Z Cry yt ey of th g t got thi pc is - .
EO, RCCUCc'E'OA. SANDWRI OY1PLYWfrHALLn'ON-PO Issued by: Date 2�
t ,
otnpplicaMCo t cm /�"' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
"1`stall'Ne appliwttafutuie Wilding oaupant nose,hadle luiirdoiu rweriel Type of Roof - -- - - ----- - - - _. _-_ ..
as d find by the Cupertino Municipal k:odChapter 912.a ad the Health and Safety ..xa f•r••r::,; :9;.:t - .• a•.. -. .,
Cad
Ely
«25532(a) ivo 1 ,,�d,�.,• ,I.
__All roofs shall be inspected prior to any roofing material being installed.
', 'Will the ft,fictim.1future building cap..,use cyai,memordevices which If a roof is installed without first obtaining awinspection',11 agreedo'remove
emit haaeNous air contaminants as defined by the Bay Arca Air Quality Management
District? , - all new materials for inspectionm. Applicant understands and will comply with
oyes,; , ONO all non-point source regulations:
Phave rcaR the Iscomdousmaiems,rayvimmem,tmder'Chapmr 6.95 of the
Coli ruin HealthA,Safety Code,Sections 25505,25533 and 25534.1 understand that
ifs a wilding does not currently have a tenant,that it is my responsibility to notify the
W upam of tha regmmmenu which must be ma PHOT to issmoci of a Certificate of
c ry'''t' Signature of Applicant Date
rte r auto erg=ot All roof coverings to be Class"B"orbetter '
.-. ...I L: . . .. �. OFFICE . . ._