02100052 CITY OF CUPERTINO , 3s�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
nulLglgG2_9DRHEATHERW00D DR A\ & H HEATING PERMrrNp2100052
QW9AM NECHAN DRAN 770 CHESTNUT ST APPUCATl4"U(J'K957F/2002
ONE: (408) 279-0722 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that 1 am liecnsed under n visions of Chapter 9lcommcncing De5it Qu a��pm
�« with Seetm 7100)",1 Division 3nr the ansines -aProresaons a,ue.arta my license is REPLACE FURNA reetl �i
in full 11lrcc dcOc'
� Lic.00 commet iL
as
u
41 -1JAN 2 2003
< ARCI1TAMIN
` /dmsla d my plans shall b:used.Zr¢ lic.xudx
U
nOtu
�3'r
Licensed Professional
J Professil BUILDING
F'u ij g OWNER-BUILDER DECLARATION
as a 1 hereby.firm that I me exempt from the Contractor's License Law for me
w C o O rolluwin,reason.(Section 7031.5,Business and Professions Cork:Any city or county $2000
e%'m which requires a permit to construct,alter,improve,demolish,or repair any structure
prior[its issuance.also requires the applicant for such Permit to file asignedsmlemeail
YSC that he is licensed pursuant(it the provisions of the Common's License Law(Chapter 9 3Y�-2.13 pi3A10i0 Valuation
¢' (commencing with Section 7000)of Division 3 of the Business and Professions Code)(it
i $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant on a civil Penaltyof
not more than five hundred dollars($50P. 303pN-N ROUGH MEC $CAL Occupancy Type
❑ I,uowt¢rof the property,or my employees with wages azlMir sole compenwdnn.
will Jo Ne wink,and the snuctme is not intended or offered for sale(See7164,Business - gpk2}{' g cam,
and Professions Cude:The Contractor's Lt...Law does not apply to an owner of 505 - FINALkP[:L Ons
Progeny who huikis or impmvea thereon and who doesswin work himself ser through his
own employees,provided that such improvements am not intended or offered for sale.If, 507 - FINAL PLUMBING
however.the building or improvement is sold within mm year of completion,the owner-
builder will have the burden of proving that he did not build at improve for purpose of 508 - FINAL MECHANICAL
sale.).
❑1,as meet of the Pmpeny.am exclusively contracting with licensed contractors to
consumer the project(Sec.70M,Business and Professions Code:)The Conuacmr'a Li-
cense law does not apply to an owner of property who holds or improves thereon,said
whit contracts for such pmjeca with a contractors)licensed Pursuant o the Conuamor's
License Law.
❑I am exempt under Sea ,B&P C for this rtamn
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby alium under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent o self-insure for Worker's Compan-
sation,as provided for by Section 3700 of the Lubsr Code,for the performance of the
work fur which this permit is issued.
�p/Q1 have and will maintain Worker's Compensation Insurance,as required by Section
fd�(N)of the Ia as Code.for the performame of the work for which this Permit is issued,
My Warter' Compensarun/nlnwmncc cam'iiu�rr and Polley nnulm W' Im�1
Canicr: �� gOicy RO ORKERS'
ERTIFICATE OF EXTON FROM WORKERS'
COMPENSATION INSURANCE
(Thissenion recd not becomple¢d if IM Permit is far one hundmJ dollars($11X1)
nrlcas)
1 certify that in the Performance of the work for which this permit is issued.I shall not
employ any Is:rson in any manner so ash)Mcome subject to the WorkersCompensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:IL at making this Cenilicam of Exemption.you should
become subject to the Worker's Compensation previsions of the labor Code,you must
OO forthwith comply with such provisions or this permushall he deemed revoked,
z CONSTRUCTION LENDING AGENCY
f� l hereby a0lrm that there is a construction lending agency Gn the arlormanc,of
6i the work for which this Permit isiamal see.3197,Civ.C.)
a. A Lender's Name
0z Lender's AJdreas
V I cenify that 1 have read this application and ma¢that the shove infnrmarion is
(L F^ correct 1 agree w comply with all city and county ordinances and state laws relating m
DU building consumaion.and herchy authorim represermitocs of this city to enter upon Ne
F aabovementionedproperty for inspection purposes.
(We)agree m sun.indemnify and keep harmless the Ci ly of Cupertino against
y ionones,judgments,exuaand expenses which may in any wily scram against said City ��
U z in PL9(IA T of DERST N of this permit v V
APP NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATIONS. �a.-
Signature of ApplicaHAZAR inn ate^ pe of
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Cu,,ant or(Muni building ecuhapt r 9.1 or handle ha alth anmaterial
as defined io the Cupeninu Municipal Code,Chapter 9.12,and the Health and Safely
Code. 0yea 25532(a)f All roofs shall be inspected prior to an roofing material being�Y" �"°— P P � Y g g installed.
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
,.if haeardoas air comment nana ash by the Bay Area Air Quality Management all new materials for inspection.
Distden
❑Ycs 0 N
1 haw read the hroadous muNrialx requiremcma under Chapter fi 95 of the Califor-
nia Ilcalth&Safmy Code.Sttlions 25N15.25533 and 25536.1 undimmed Nat if the Wilding
Jte n currcndy haw a¢n nt that it is my responsibility m nobly the occupant ail the
rewire Lswnienmure, ortuissoamena rtieeam a.,PsocY V Signature of Applicant Date
Owner it aul prised agent K-: Dale All roof coverings to be Class "B"or better