02100083 (2) CITY OF CUPER77No
BUILDING DIVISION PERMIT CONTRACTOR INF.ORMAT ION:""
��r � .
BUII.> DR AM S TOWN DR ATLAS HEATING PERMIT N®2100053
owSOBEq eSERRE 155 SAN LAZARO AVE APPLICATIThUY°PCTf 2002
ZONE: —74W-739-0516 SANITARY NO. 7 CONTROL NO,
ARC I I ITECT/ENO[NEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u-00 LICENSED CONTRACTOR'S DECLARATION
� p 1 hereby allirm that I am licensed under,pmvisions of Chopin 9(commcncin6 es r O
O wnh Section nsahsf Division3of the Bux�sanJ Professions CnJc,unJmyliccnu is REPLACE FURNACI �LJll 1/C
Z02in full fn cant CU t� s7
a? Li xC FINALE®
�NfS I
N. O
I undermanJ my plans s all be uuJ as puM1lic records
LLot; LicetsedProfessinwl JAN 0 .S 2003
y 5 OWNER BUILDER DECLARATION
d<f 1 hereby allirm that I um exempt Imm the Cnnowho's License Law Int the e', p� $10000
3600 following whon.(Section 7031.5.Business and Professions Code:Any City orcounty
urepILDIiVG
which requires a permit to ennsct.alter,improve,demolish,nr air any structure BU
prior b)its issuance,also requires the applicant for such Permit o file a signed statement
that he is licensed pursuant In the provisions of the Contractor's License lsw(Chapter 9 3 6I.1.a0O&2AIU Valuation
r E�G (commencing with Section 7100)nf Division J niche Business and Prnleschnns Code)or
?
of
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty ofpN'N Occupancy Type
not more than fee hundred dollars(ss)o). 303 - ROUGH MECHANICAL
,i ❑
1,co;owner of the property,or my employees with wages a their ole compensation,
will do the work,and the suction,is not intended or offered for sale(Sec.7044,Business �g{''
and ProTh
Professions Code: e Commutes License Law ones of apply m an owner of 505 - FINAL �6k„ ieAb
ITpAUI[Ions
property who builds or improves thereon,and whodoes such work himself or Through his
own employees,provided OxIsuch improvements arc not intended or offered for sale.If. 507 — FINAL PLUMBING
however,the building or improvement is mid within one year of completion.the owner- SOB — FINAL MECHANICAL
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑ 1,as owner of the properly,am exclusively contracting with licensed contractors to
ennsucl the project(Sec.NW.Business and Professions Code:)no Contracmrf Li
reme Law does not apply to an owner ofpmi eny who builds or improves thereon,and,
who commons for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
[I1 am eaempl under Sec. ,B&P C for this reason
1wocr Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty ofperjury one of the following declarations:
hese end will maintain a Cenifica¢of Conxnuo self-insure for WmkelsCompcn-
n,u provided for by Section 37M of the labor Cie,for the Performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code.(or the performance"(the work for which this permit is issued.
it ')s/C'/ompeGsation lnmrangpe co ier and Policy number am:
CERTIPICA OPE%EMPPON MWOR ERS'
COMPENSATIONI R NCE
This section need not he completed it the Permit Is hone hundred dollars nlf(b
or l.")
1 certify that in the Performance of the work for which this Permit is issued,l shall not
employ any person in any manner m as To became Subject n the Wnrkera'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,doer making this Cenil icae of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code.you must
Oz forthwith comply with such provisions or this Permit shall M deemed evoked.
z O CONSTRUCTION LENDING AGENCY
[-+ Ihereby alTrm that form is a consucbmn lending agency for0e performan.c of
Ix7 the work for which this pmmi l is issued(Scc.NAP.Civ.C.)
QLender's Namc
z Lender's Address
V P 1 certify Nat 1 have read This application and state the the slam iwsmmuiun is /1 _
0 U cuildin 1agree mComply
and with all city and countyordinancesand statelawsrelating a
V idiewngcttiodednnand I imvuchnriprose.representatives of Niscity toenter upon the
W ahovc me ei agree
to ertysave find m indemnify
an keep hs.
(We)agmen hs save,indemnify and keep harmless they Ty of ndCuPcnstid Ctagainst
jj liabilities,judgments,of
hoind cf this
erit. may in any wayaccrue against sail City /
APPLI ANT of UNDERSTANDS
"f This Persil. L/
V z APPLICANT UNDERSTANDS AND WILL COMPLY L NON POINT Issued by: Dale
SOURgAliGuLAri NS.
-Awte Si col'
ApplicandUCcommI
n,
IIAZARD S MATERIALS DISCLOS Type of Roof
Will the applicant or future building occupant store or Jlc harardom mmeriul
as defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cndc.Sc a inn 255121a)? All roofs shall be inspected prior to any roofing material being installed.
❑
yo
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Wit hilwous air comamirmas If&fired by the Bay Arca Air Quality Management all new materials for inspection.
Discrin7 '
❑Yes
1 have mad the havardna materials mciffirearchistiockr Chapur&95.f the Califor
fix Health A Safety Code.Sections25505,25533 and 255.3W.1 undeis ad that ifda:building
fres no ntlyfw u cram"thus his my eslgosihilit dl'y tM recupa n of the
nrp Matninon, foc..IF . SignatureofApplicant Date
ownermaathnrixed agent ,te All roof coverings to be Class "B" or better