09020022BUILDING DIVISION PERMIT
20400 MARIANI AVE
OWNER'S NAME:
ARCHITECTIENGINEER:
o p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
Z w with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect L '^
i 2? License CI s I� Lic. A Q I
O Dale Contractor
F- � 1 AsaHITECrS DECLARATION
K-.Cc understand my plans shall be used as public records
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O vFi Uccnsed Professional
h OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License law for the
j O OO following mason. (Section 7031.5, Business and Professions Code: Any city or county
3 $ which requires a permit to construct, alter• improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
S 0 that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
uf— (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
.. that he is exempt therefrom and Use basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ 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 forsale (Sec.7044, Business
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 orthrough his
own employees, provided that such improvements are not intended or offered for We. 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.).
❑ f, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense law does not apply to an owner of property who builds or improves thereon• and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License law.
❑ I am exempt under Sec , B & P C for this reason
XL C
(408)271-2425
PERMIT NO.
PERMIT L95UE DATE
S A
CONTROL NO.
BUILDING PERMITINFO
BLDG
ELECT PLUMB
Job Description
VISE-2 CONDENSING UNITS REMOVED FROM.PLANS &
PLACED W/2 PACKAGED AC UNITS, ORIG# 08090060
Ft. Floor Area
Valuation
APN Number I Occupancy Type
31622018.B3B
Required Inspections
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
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3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worrkkeess Compensation Insuram a c�a_mer�andd Policy number are:
Carrier. Ll_sT�2 �l'"�tdlic�lNa�' vAs' o
1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars (SI00)
or less.)
f certify that in the performance of the work for which this permit is issued. 1 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 Worker's Compensation provisions of the Labor Coda you must
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forthwith comply with such provisions or this permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a conswetion lending agency for the performance of
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the work for which this permit is issued (See. 3097, Civ. C.)
W Q
Lendcrs Name
aLenders
Address
U Q
I certify that I have read this application and state that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
Vbuilding
construction• and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
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(We) agree to save, indemnify and keep harmless the City of Cupertino against
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liabilities, judgments, costs and expenses which may in any way accrue against said City
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tom-
in consequence of the granting of this permit.
APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SO C GUL O S. _
Re -roofs
Signaturcol'ApplicaTUContra or Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or futum building occupant stom or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Codc.Section 25532(a)7 t-. /
YesWill
All roofs shall be inspected prior to any roofing material being installed.
[3
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the say Area Air Quality Management
all new materials for inspection.
District?
❑Yes (fir
I have read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & SafetyCode, Sections 25505.25533 and 25534. I understand that if the building
does not curmnd have tenant. that it is my responsibility to notify the occupant of the
m ff.. ich u t be met prior to issuance of a Certificate of Oc "I
Signature of Applicant Date
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All roof coverings to be Class or better
Owner or ag t Date
Ow