03020102 CITY OF CUPERTINO ?
BUILDING DIVISION PERMIT 9,coN-RACT0 I-NFOR 1IATION,
BU157ANGADURESS: ATLAS HEATING PERMITNO.
19897 BEEKMAN PL 03020102
OWNER'S NAME: 155 .SAN LAZARO AVE Puma LSSUE DATE
MCKEE JOHN R AND JEANNE D 02/25/2003
NE: (408) 739-0516 SANITARY NO. CONTROL NO.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0, LICENSED C'ONIRACIOR'S DECLARATIONO O
1 hereby n
afee that 1 em licensed under previsions of Chapter 9(commencing Job Descriptio
with Section 7")or Division 3 of NC Business add Professions Code,and my license is
inpull mre.andeffea REPLACE FURNACE MAR 1 0 2003
Licenw Clans L'c.N
t-p
Data Comnscor
7W ARCHITECTS DECLARATION
< 1 ndcrwndmypramshall Iused as Chiledmords
BUILDING
c
+0 Licensed Professional
,� OWNER-BUILDER DECLARATION
a9 e I 1 hereby affirm that 1 am exempt from the Comractoes License Lew far the -
yp0 following mason.(Section 7031.5,Business and Pmfessiuns Code:Any city or county
u�$ which requires a permit an cnmtruct,alter,improve,demolish,m mpsir say structure -
Fiy poor In itsinuanec,aBu requires the applicant forsuchpennit I.(Iles signed wtement
Ila that W is licensed pursuam to the provisions of the Contractor's License Law(Charter 9 Sq.Ft.Floor Area I ion
tt$ (commencing with Salton 7000)of Division 3 of the Business and Professions Code)or
3
that he is exempt therefrom and do basis for the alleged exemption.My violation of
Section 703"by any appliesnt fan a permit subjects thc applicants m a civil penalty of APM
not more Nan five hundred dollars(g500h r �CCupanCy Type
❑1,m owner ofthe property,or my employees with wages u Neil sole compensation,
willdo Ne work,end the smctum isnotlntended oroffered fonds(See.70u,Business
aM ProfeYlaM Code:The Commoner U.Law dam nm apply an a s..of 303 - ROUGH LOi ns
property who builds w improwathereon,andwho doessuch workhimserfor through Ms __
own employees,provided thatsuch lmpmvemenu are not intended oroRered formic.It. '304 - ROUGH ELECTRICAL - -
however,the building or improvement is sold within one year of completion,the owner.
builder will have ORburden ofproving that Wdid net Wild wimprove forpurp¢
aaf 505 - FINAL ELECTRICAL
.Area. 507 - FINAL PLUMBING.
❑1.as owner of the property,am exclusively contracting with licensed contractors to 508 — FINAL MECHANICAL
construct the project(Sec.7044.Business and Rofeuions CodeO The Contractors Li.
came law does not apply to an owner of property who Wilda or improwa thereon,and
who Contracts fm such prejecu with a conuaemr(s)licensed pursuant an OCR Conuaesor's -
Liceme Law.
❑1 antexempt under Sec. ,B&P C for this reason
Data
WORKERS COMPENSATION DECLARATION
1 hereby aim under penalty of perjury,one of she following declarations:
Or'.and will esimain•CeAfica..1'C...t an self-imam for Worker.Contract.
section,as provided fan by Section 3700 of the labor Cade.fm IN Performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Imunnce,an required by Section
37W of the labor Cods,for the perform...of the work for which this permit is iuued.
My Workers Comlewtion Insurance carrier and Policy number am:
C.". Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThLs aettlon need nosbecompletediflW permit is found hundmddnllan(SIM)
or lem)
I cenify that in Ne pcd(mmanea of the work for which this permit 0 issued,I shall nut
employ any pawn In any manner ad as an become subject to the Wo d m'Compemadon
lawn of Califoroia Data
Applicant
NOTICE 70 APPLICANT:If,after reeking his Cenificete of Exemption,you should
become subject M the Workers Compensation provisions of the labor Code,you must
.J Z ro d with comply with such previsions or this Permit shall W damsel revoked.
zO CONSTRUCTION LENDING AGENCY
Thereby aRrm the'then is a construction lending agency for the perfwma=of
F" lOR work ander.for which this permit is issued(Sec.3M.Civ.C.)
W
G Landers Add.DZ
U Q 1 certify that 1 have.ad Nil application and sante that the above lot ..it..Is
t4 F coned 1 time to comply with all city and county ordinances and stoic laws milting to
OU Wilding conswclian.and hereby authoriordermsenutives of this city an enter upon the
If7
above mentioned!propc costs
forinspectionpurposes
(We)Agree to save,indemnify and keep harmless be City of Cupertino against
y Inconsequence of
uang expensesmit. may In any way acemc against mid City
U z In consequence of the greening of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Signature of Appbcanl/Conuwmr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the aPPlicam or future Wilding occupant atom or handle hamodous material
M donned by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
C.Section 25532(81 All roofs shall be inspected riot to an roofing material bei.
Yes ❑Na P P Y g g installed,
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or future Wilding by the B use m Air Qu w devana which P g
IAr fi7afdous oil contaminants u deRncd by the Bey Arta Air Quality Management all new materials for inspection.
❑Yes C]No
1 have read the haerd.us materials requirements und.,Chapw,6.95 of thc Califor-
niaHealth Re Safcty Code,Secuous 25505,25533 end 25534.1 undersmnd that if thc Wilding
does not cumcmly have a tenant.this it u my resparcubduy m.61,OR acupans of the
requirements which must W mel poor an issuance ora Certificate of Ompwry Signature Of Applicant _ Date
Owner or amhorined agent Dam All roof coverings to be Class"B"or better