02070006 CITY of cuveSIOCONTRACTOR INFORMATION:
lBUILDINGDIVISIONvtstoN PERMIT
BY69Ql`uUMNZANITA COURT TECHCON PERMIT V2070006
41ypRnIE:PANACCIONE 17450 MONTEREY ROAD APPLICA}tGA'$116T/7.2002
` PHONE: (408) 778-1350 SANITARY NO. CONTROL NO.
o s 2 ARCHITECDENGINI ER: - BUILDING PERMIT INFO
O❑O❑ - BLUG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
i I hereby alarm than I mm licensed unset provi,hm,urChapter 9(commencing GAS LINE
p
u: with Section 7000)of Division 3 ofthe Business and Professions Code.and my license
is in fan area and effect.
atp
oU License Class Lie.p FBN A13
I 3. Date ,,-
�H Ice Can,,-
ac C ARCHITECT'S DFCLARATION
1 mossomnd my plans'coal]he Lined e,public reenacts
Tse JUL 0 2 2002
E o o Licensed Pmfcszinam
'xca DN'NER BUILDERDECLARATION
1 hereby arm that 1 am empt mfrom the Contractor's License law for the
_� affirm
following reason. 7031.5.Business and Professions Code:Any ed)or county BUILUIN 7500
nr
E d which requires a peal ,emonact,altar.improve,demolisM1,or spam any cmcmre
i
3= prim to its issuance.also requires the applicant for such pcmu
io file a signed statement - —
tMlhe,islicense,'pursuant to the poo wins of the Contractors License Law(Chapter 9 r 13,q.ER.G2c6r.ArOa.3..\ ff Valuation
(commencing with Section 9000)of Divimmn 3 of he Business and Profession,Code) ... f
or that he ii escu pt therefrom and toe basis for the alleged exempiou.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
ofart rtrore ban five hundred dollar,($500). 304APN 1RiHDAtfaLH ELECTRICAL Occupancy Type
01,as owner at he prupary.lir any ea,ployccx with wages as their sole crmpemsaion. 501 - FINAL ELECTRICAL ENERGY
will do the lark. ad the wuaure is non intended or offered fur sale(Sec.7044,
Business alk Professions Code:The Contractor's License law does not apply m an6t4 CtlOn$
owner of property Who build%or improves thereon,and who docs such work himself
armrough his awn empinvecs.provided hat such improvnnems Lire not intended
offetM w
for sale.If,however,the building or improvement is sold within one year of
completion,the ownerhulldcr will have the burden of proving that he did not build or
improve for purpme of sale.).
❑Las nwder of he proinnv, at ceclusivaly contracting with licensed contractors to -
trammel the project(Sec.7194.Business and Professions Cade)The Contractor's
License Use dao not apply to an owner of propcny who builds or improves hereon,
.und who contracts for such projects with a contracu nO licensed pursuant to he
Contmcmr's License Use ,
01 am exempt under Sec .B A P C for this rcawn
Data
WORKER'S COMPENSATION DECLARATION
/ 1 hereby affirm under penahy of Perjury one of the following decimations:
f. �.i ❑ 1 have and will nuinmin a Carnival, of Caren, to zdf-insure for Worker's
\`�i✓/ Compensation, as provided for by Section 37W of the Labor CWe, for the
performance of the work for v hich thio pcmit is issued.
01 have and will nuinmin Workers Compensation Insurance,as required by Section
37W of the Labor Coda for the performance of the work for which this permit is
issued.My Worker's Compensation Insurance carie and Policy counter are: _
Carrier: ( 1 Policy No.: _ - . tri
CERTIFICATION OF EXEMPTION FROM WORKERS'( ! + +COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars
(5100)or lar.)
I certify that in the pa,mmmea of the work for which this i,emit is issued,1
shall not employ any person in any manner so as no become subject to the Workers
loft Compensation Law,of Criterion.Date
Appleom' -
NOTICE TO APPLICANT:If,after making this Comficate of Escntptien,you should
becomCwbject to the Worker's Compcnsadon provisions of the Lather Cede,you most
forthwith comply with such previsions or this permit shall he deemed raveled.
Fy ". I ' ' CONST RUC TION LENDING AGENCY' n
Y 1 ncieby affirm that theta i,a mnsmction lending agency for the performance
of the work for which his peon is issued(Sec.3097.Ci,C.)
CL L.emlKs Nance "
7 Z LcrAer1 Addresz
V I certify nom I have and this application uad stare hit, above information cion is
V. U t.at.Wild I agree to comely with all city and eepmy rdativess and rotate rows relating
V to buildingconlioned nn,property
bauuhoris parm umativa of this city to carr upon
the nno(we) ,,,a in properad lir i fy ad kn p harmless
ar le
f y (we)agree ts save,indemnify and keep hm may
in me Cita of Cupertino against
rZ liabilities.judgments,costs and iexpensesifthis
which may in any way accrue against said )
(,) ,Z, city in consequence NDnrnbegranting of Thi,LCO �V
SOURCE REGULATIONS.
AND\VIL�COSIPLY WITH ALLNON-POINT Issued by: Dale t
SOURCE REGULATIONS, y'
Signature of ApPlicanAC RDOU Data
Re-roofs
I{AIARDan, MATERIALSopo DISCLOSURE'
WillytheCaper onfmunillid ngrtuyapto.re r9.12. ad doandle,
lthandSmrial Type of Roof
as def Sect by me 32m)?nn Municipal Cade.Chapter 9.11.end the Health and Sofay ,
Cade,Section 2551214)7 - '. ..., .,4,(: � .. •. •. � • , .
❑rem'' `❑No'' All roofs shall be inspected,prior to any,roofing material being installed.
Will the applicant or future building occupant use equipment or dances which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous at,a mounduars as deiced by the Bay Area Air Quality Management . ..
nimbler. all new materials for inspection. Applicant understands and will comply with
It, Oyes 0 N all non-point source regulations.
I have read the memenui materials requiremeau ands,CM1apser 6.95 of the
California Health d SSfay Cudc Sections 25505,25533 znd 25534.1 understand that
if the boilding Jaz oat curently leve a mount,that it is my msponxibdity to miry the
occupant of the paposamcna which mus be Oct prior to issuance of a Certificate of
Occupancy Signature of Applicant Date
owner or aahari=ed agent tote All roof coverings to be Class "B" or better
_ - OFFICE