07070054 77777777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT ► Z '
PERMIT NO.
BUILDING ADDRESS:
19752 BIXBY DR ATLAS-TRILLO HVAC 07070054
PERMIT ISSUE DATE
OWNER'S NAME:
BOGEN MARJORIE 1965 KYLE PARK CT 07/09/2007
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITEC(ENGINEER: ADD A/C UNIT. BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION - Job Description
uJ I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professionsnd my license is
=y in full force and of t Opp
z License C Lte•
•t-p Datc ConE_FK
� ARCHITECTS DECLAR T O
1
W.< I understand my plans shall be used as public records
taU
U.I- Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
3 p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
%m which requires a permit to construct.alter,improve,demolish,or repair any structure
r"y prior to its issuance,also requires the applicant for such permit to file a signed statement
z, q.Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
t= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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 the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
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 contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's la-
cense law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a comracwr(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
L]I have and will maintain a Certificate of Consent to self-insure for Workces Compen-
sation,as rovided for by Section 3700 of the Labor Code,for the performance of the
work r ich this permit is issued.
and will maintain Worker's Compensation Insurance,as required by Section
00 of the Labor Code,for the performance of the work for which this permit is issued.
y Workers Compensation Insurance ca .er and Policy number am:
Carrier. Policy No.:
CEIMFICATE OF EXEMPTION FRO woke Rs'
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is forone hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workces Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
F~"En I hereby affirm that there is a consuuctinn lending agency for the performance of
p:.7 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
0 z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
t1. 0-4 correct.I agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,iptlMents,costs and expenses which may in any way accrue against said City
U Z in co nce f the grantin is permit. Date
"- APP DER S AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUPE GU S.
Re-roofs
sign re of Applican Date Type Of R)Of
HAZARDOUS MATERIA SCLOS RE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codc,Secuon 25532(a)? All roofs,hall be inspected prior to any roofing material being installed.
❑Yes Kturae
Will the applicant orilding occupant use equipment or devices whichIf a roof i:,installed without first obtaining an inspection,I agree to remove
amit hazardous air contaminefined by the Bay Area Air Quality Management all new m iterials for inspection.
District?
❑Yes ❑
I have read the hazlrrd aterials requirements under Chapter 6.95 of the Califor-
nia Health& Codc, tions 25505,21b3 and 25534.1 understand that if the building
does not c tl h a nano te my responsiM?E
'
requircm Is prior to issuance of aSignature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent