09060095 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � RF� � � MsT�� .
BUILDING ADDRESS: PERMIT NO.
1186 RUPPELL PL VALLEY HEATIN
OWNER'S NAME: PERMIT ISSUE DATE
' A 0 9 9 CONTROL NO.
(408) 24-6290
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION lob Description
U C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
ro with Section 7000)of Di'cion 3 of the Business and Professions Code.and my license is
y in full in and eff �z b RPLC FL RNC, ADD A/C UNIT
j n? License C Lle•><
F in Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Dw<
y O y Licensed Professional
n y� OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License law for the
HO following reason.(Section 7031.5,Business and Professions Code:Any city or county
<m 046 which requires a permit to construct.alter,improve,demolish,or mpair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 Sq.Ft.Floor Area Valuation
rac
Y F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5999
y 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($5=. 362230C47 . 00
❑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 q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sale.it,
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 Li-
cense Caw 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 contractoes
License Caw.
❑I am exempt under Sec B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
-on,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
3700 of the Labor Code,for the performance of the work for which
rwwtyhiccch this permit is issued.
My Wor mpensad An Insurance Cartier and Poliry��-�L �
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM
ORKEtS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for ono 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,atter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
E r I hereby affirm that there is a construction lending agency for the performance of
(Yr the work for which this permit is issued(Sec.3097,Civ.C.)
a A
Lender's Name
Lender's Address
V 0 1 certify that I have read this application and state that the above information is
GL corccL I agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorim representatives of this city W enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City /1
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTAN S AVD WILL COMPLY WITH ALL NON-POINT Issued b.- Date 0�
SOURCE .
Re-roofs
SignatuAbvft
t/ n r T of Roof
AZ S MATERIALS DISCLOSURE Type
ant art future building occupant store or handle hazardous material
as deftertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Lf7•++15—
If a roof is installed without first obtaining an inspection,I agree to remove
Will Inc applicant or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Bay Area Air Quality Management all
Act?
❑Yes o
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- T/
nia Health&Safety Sections 25505.25533 and 25534.1 understand that if the building U
docs not
Dae All roof coverings to be Class'J 'r or better