02100152 CITY OF CUPERTINO
BUILDING nlvlstoN PERMIT IC07RACTOWINFORMATIO T
BUl A))Dlz� THERW00D DR A PERFECT CLIMATE PI:RMITNg2100152
O1w9Ryk"LY GARY L AND MARIETTA 10570 S DEANZA BLVD APPLICATP0sPTgTJ2002
H)NE (408) 861-9545 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTR ACTOR'S DECLARATION
I hereby eflirm that 1 am licensed under provisions of Chapter 9(commencing y
wi th sectlonlR4kl)nf Division 3 of the 13usine and Professions Code.and my license is REPLACE EXIST IN'QG DeF' SI�L.'E
x,Oh in lull how and cif t
Z O g{Z uccn Clans I,ic.M
O N'yF'y O )m �� Cnm��ruy�n�/Gu/t�A
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I understand m InaQtA
s shall M uewdPag R cords
n O w V y p puhhc rttarJe
nM Licensed Professional
OWNER-BUILDER DECLARATION
u�<� 1 hereby affirm that I am exemm from the Cnmricim's Liecnse Law for the $2 612
o—O O fnllnwing femora.(Secdom 7031.5,Business and Professions Code:Any city Or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
HZipnn 1.it isuance.also requires the applicant lorsuch Permit o Eleasigned statement
that he is licensed pursuant to theprovisions of the Contuclnis License Law(Chapter 9 33i}9@t6I0@eB AfB6 Valuation
sSf O (commencing with Section7(X)b of Division 3 of the Business and Professions Code)nr ,
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a ric mil subject the applicant to a civil Penalty of PN N Occupancy e
or
nut me than Me hundred dollars(s50)' 303 ROUGH MECHANICAL p Y TyP
D 1,m owner of the property,or my employees with wages as their sole compensation,
Will do the work,and the someone isnm intended or Offood torsade(Sec.7044,Business 5194 Reeef
T �(
and Professions Count The Co mucto's License Law does not apply o an owner of 505 - FINAL! 9Pgneons
progeny who builds or improves thereon,and who does such work himself or through his
own employees,provided mal such improvements are not intended or offered forum,If, 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion,the owner, SO8 — FINAL MECHANICAL
builder will have the burden of proving that he did not build or improve for purpose of
aide.).
D 1,as owner of the progeny,am exclusively contracting with licensed contractors 1.
construct d project(sec.]roan Business and my wh ions Cade9lTe Connector's rad
cense Taw Jos not applyje an owner of propcns who Wilks m improves Connector's and
whocontractsL. for such projects with a nmwnogs)licensed Purauem m the Convenor's
License L.
❑ I am exempt under Sec. ,B&P C for this reason //aa
Owner Dale
IWORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury,one of the following dcelar stions: 1�
I have and will maintain aCenifcateofConsentmself insane forWorker'sCompeerlion,as provided for by Section 371X1 of the LaborCode.for the performance of the
wink for which this permit is issued.
D 1 have and will maintain Worker's Compensaion Insurance,m required by Section
3700 of the labor Cm1c,for the Performance of Ne work for which this permit is issued.
My Worker's Competition..nlnsaurnm carimand Policy num/fileran a^7�
Ca cn I�1G C dLN ofdy No.: rs qS-6
C RTIFICA FEXEM NFROMWORKERS'
COMPENSATION INSURANCE
(This section need nil he complmed it the Nomil is fnnme hundred dollars($100)
nr less.)
1 cenify that in the performance of the work for which this Permit is issued,1 shall mol
employ any person in any manner sr,m m become subject the Workers'ComPensalion
Laws of C.jifomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcaw on Exemption,you should
become subject t0 the Worker's Cum pe nsutinn provisions of the Labor Code,you must
O 0 forthwith comply with such provisions nr this Permit shall W deemed revoked.
'Z ry CONSTRUCTION LENDING AGENCY
[—r I hereby affirm at
share is a construction lendingagency fur the Performance of
C the walk for which This permit is issued(See 3097,Civ.C.)
GQ 1<ndcr's No
z lender's Addmm
V O I certify Nat 1 have read this application and auto that the above information is
V. (✓ correct.1 agree o comply with all city and county ordinances and state laws rclaling to
O V building c.nsWction,and hereby andurimmprescnulivesofthis city toenter upon the
r W above-mentioned property for inspection purposes.
y (We)agree In v..indemnify and keep harmless the Chy of Cupcmnu against
ry Iiabilities,judgmcnt,cost and expenses which may in anyway see=against said City
U in of this Noub.
APPLICANT DERSthe nA DS AND WILL COMPLY W1Tll ALL NO "POINT Issued by: �60 Date tt//
SOURCES .ATIO '
Re-roofs
ria fApPlican .onvazmr Dam
11 ZARDOUS MATERIALS DISCLOSURE. Type of Roof
ill the aPpli,m Or future building Occupant store Or handle heaadous material
as defined by the CuNmin,Municipal Calle,Chapter 9.12,and the Health and Safety
Cods.Section 255121n)7 All roofs shall be inspected prior to an roofing material beim installed.
❑Yes No P P Y s s
Will the applicant nr Tula building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree[o remove
omit Li mous air comaminames as def red by the Bay Arca Air Quality Management all new materials for inspection.
Dimftell
Dyes o
I have read chuuNO mum riadsmgnlrcmenksunJcr Cha lar 6.95oftho Califnr,
niaflcalI&Saul 'oJc,Sc''ms 55115,25511 and 255341 on�crs dlhal if the building
dosnilcunent uvculc I,Nat it is my resWnsihility,,mm cupan,of the
reyuircmem,w chmun elpnortnismann faCeriticaeof err. Signature of Applicant Date
wrier or oIVr5cd age Date All roof coverings to be Class "B"or better