01120071 (2) CITY
NGDPERONNo
IL DINGPERMIT
ADCONTRACTOR INFORMATION:
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BUILDRESS: U a //A PERMIT NO.
L 1N� A PERFECT CLIMATE 01120071
OWNER'S NAME: APPLICATION SUB DATE
CHEROL LUM 10570 S DEANZA BLVD 12/18/2001
I .IONF: (408) 861-9545 SANITARY NO. CONTROL NO.
O OFARCHI=/ENGINEER:/ENGINEER: BUILDING PERMIT INFO
<U BLDG ELECT PLUMB MECH
yah r� u u u
LICENSER CONTRACTOR'S DECLARATION
5 v z - lob Descripption
by affirm itis lam liccnud under provisions of CM1apmr 9lcommennng INSTALL NEW FURNACE IN EXISTING LOCATION
F-m7lNYJ)of Division)of Nc Business andP fes>i, CnJe dmy licensetor
a E= af5.,+�:m rt `V�iif1-I. QARCr HITECf'S DEContCLARATION
v< 1 and`errslwnd my plans shall be used as public mcmd,
i`e1
i d c O Licensed Professional
ac
5�1OWNER-BUILDER DECLARATION
ou—v 1 hereby affirm that 1 am exempt form the Commam's Licenx Law for the
z following teason.(Section 7031.5.liusinex and Professions Crile:Any en,or county / $1945
aeF C which requires a permit to construct,other.improve,demolish,or repair any structure 359 h I �1 D/�
C� prim to its'issuance,also requires the applicant fur such boon t to file a signed stmcmcnt
a. that he is I iccrvcd p %io Tto the phavisions of the Contractors License La (Chapter 9
(tmormoseir,.ithSchi7000)vfDii,vm3nfineBminessad . ons
nPofeCode) t'i-;`; t X33 �..''a'1.\i !•i,itv-d: Valuation
or that he 14 caempt thchdrom and the basis her the alleged exemption,Any violation ..
of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty
of not more than five hundred dollars S500). 3 0 j\pN rkF tUH PLUMB I " Occupancy Type
01,aso r of the property of my employees with wages as their sole compensation.
will do the work,and the sometime is not mended or offered for sale(Sec.7044,
eudneis one Professions code:The Contractor's License Law does not apply to vn 3 04 - ROUGH EBtE (dtPd2lDfi tions
or through rofproperty Who builds orimproves thereon,and who does such work himself 505 - FINAL ELECTRICAL
or through his own employees.provided that such improvements art not intended or ____
offend for sale.If,however,the]hmong or improvement n sol)within one year of 0 - — - - - -------
completion,
---- -' --
<omple6on,the owner.mmaer will tax me�trden nr proving that tie ate not stud or 5 0 7 - FINAL PLUMBING . '•!' .. .. ..
Improve for purpose of sale.). 508 - FINAL MECHANICAL
0l as owner of the progeny, m exclusively contracting with licensed contractors to
: construe,the phsce,(Sec.7000 Business and Prrfios,imi,Cod )The Contractor s
Lice se Lax tl«s not apply t M p perry no builds improves N con, �0 -
uad who r ram,s for such Prolens with c c d)liar. d.p .rant m the
Contrnnor Larnsc La IP:N
❑Ivn exe t ,der Se n G.hB&PCfor this mamaV
Dwyer. ' h U A 2AT SEP 1 2 �®
W R ;S C PENSATIO I N
20
the by rfo n a , y of perjury,one of the following declam wiref Q� 02
;51 0 1 have and will maintain a Cenifcahe of Consent to self-imus for Worker's
�'t=y Compcnsethor as provided for by Section 37W of the Labor Code, for the
performance of the work for which his permit is issued.
_ - O I have and will maintain Worker's Compenxti er Insuranec as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is
sued My Worker's CompensationaMInsurance carrier and Policy n//um,,baae�rr m:
Cann 1y�For icy No ISUD'—t�y
.CE FICATION OF EXEMPTION FROM WORKERS')
Q .�1 '� Y rt.:Art!t�•1 1�1.,.•.' tAt':T°` `• t
COMPENSATION INSURANCE„
(This scdion nail nm he completed if the permit is fm one M1undxtl dollars h'.'a i o 4" l,k""
(81 W)or I<ss.7
1 certify that in the performance of the work for which this permit a Worker 1
nCompensation
om not employ any person in any ate sur as to become subject m the Workers'
Comicant on Laws of California.Dam
Applicant - .. -_ . .... ... .. _ _ .. _ ..... ..
NOTICE TOAPPLeWork H,Co making this Ccninsof of Exemption.you should!
0 0 become subject m the Worker's Compensation provisions of the Labor Code,you most
forthwith wmply with such pmvisians.,,his pcmtit shell he deemed rcvakcd.
Z
.E. y CONSTRUCTION LENDING toriAGENCYagency
a ; 1 hereby or w ich that there is a issued
(Sec. lending agency for the performance
�.,.., of Ne work tali which Nit permit is issued(Sec.31)97.Civ.CJ
Q Lender's Name -'•.. .__.. -" -. .. - .__
Lemler's Adaresd ,
U Q 1 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 telao,
U to building consirbetion.and hembi authonx rcpmunmtives of this city to enter upon
W the abovementioned property fm inspection pur,oves.,,
E„ 0. (We)agree io save,indemnify and keep harmless the City of Cupertino against Es
U!) Iiiii kio,.judgment,,ens..and expenses,which may in any way accrue agamst said
U Z City is consequence of the gmming of thisw��''ee.mit,, _ ' '
-^
APPLICANT LRDE til'ANDS'AND 'iLCOMPLYW1THw NONP iidT Issued by: r Date 12-1
UR
$ C'R ' 4T ONS. Y'
Jsigint., n App ieany pnnamt Dole..; Re-roofs
M RD0 t MATERIALS DISCLOSURE
W IN applcant or f m building occ pant mm in historic haxirdoxry—led.) .. Type of Roof —'--" '_. - ... .'• - - -
as defined by the Cupertino Municipal Cod Chapter 9.12.and the Health and Safety : s
Code'Section 2553200 y/, t a .': 1
ores f.m' , ,.,� ,. _ _-,All roofs shall be•inspected.prior to any-roofing material being.installed..-
Will the applicant or f t re building hoopent use equipment or des ices which If a roof is installed without first obtaining an inspection,I agree'to remove
mith 'd itcoma t adefined 65 th Bey Area A' Qualu3 Management
isomer? _ all new materials for inspection, Applicant understands and will comply with
11
0 Yesall non-point source regulations. . ,
+� I have read 0m haaardors materials rcquirememts under Cbepm116.95 of the
California Health&Safety Cade.Sections 25505,25533 and 2553x.I understand that
i(,he building does not curentlY have v henm,tha it is my So,r ibility to notify the - -
«fupan, of the require ems which must br met prior to issuance of a Cenifiwm of
°rupancy•- Signature of Applicant Date
e raum, sea ager, Date All roof coverings to be Class"B"or better
.... .. .. . ..... :..._. . . -... .. . . OFFICE .. .