02120025 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ?3.'
ffidILJ)IWLjBIAWI;sLEOLA CT # 2 AIR QUALITY HEATING & AIR Oid+ITN(02120025
1U?Q N*1KE C AND TSAI F ET AL 1233 PEDRO ST APPLICATI142"A5�2 0 0 2
IGNE. 4 0 8 2 9—3-713 8 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
�Oo LICENSED CONTRACTOR'S U[CLARATION
I Wrathy.1111.that I am licensed under provisi.a err Chapter 9(commencing b escrl tion
��R with Sectino 7lXXdd Division 3.1 do Riounemmal Professions Code.undmylicenm NEW WALL HEAT�PZ n& p
EEEE Lmnforce eClassderf«t. SHUT OFF FLEX�Sg�(-J ALE®
License Class Lie.x o B
��— Date contractor
ARCIIITECTS DECLARATION (�
1 understand my plans shall be used as public records DEC O 2002
a Chu 9
Re LLOy Licensed Profcsaiomd
y 5 OWNER-BUILDER DECLARATION
<Y I hereby affirm that 1 am exempt from the Connector's License Law for the
BUILDING
W a O O following reason.(Section 7031.5.Business and and Professions Code:Any city err county
Owhich requires a Permit to construct,aper,improve,demolish,or repair any structure $800
�Zy Primo its issoance.also requires thcapplicmnforsuch Permit o File assigned statement
ps< that he islicensed.....nunthe provicionsnfthe Cooloo nxLicemoLaw(Chapter9 Sq. Ft. Floor Area Valuation
y+Fa (commencing with Section 9(kX))ofDivision 3ofthe Iboinesaand Professions Code)err 37504023 . 00
that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects 0e applicant to acivil penalty of APN Number Occupancy Type
do(...than five hundred dollars(S50). 502 - FINAL PLUMBING ENERGY P y yp
p 1,as owner of the property,or my employees with wages as their sale compensation,
will do the work,and the swnum is not intended or offered for sale(See.7044,Business 5E)6 GAS
and Professions Code:The Contractor's License Law docs not apply In an owner of 507 - F I NAL AY99yftections
property who builds or improves trencher,and who does such work himself or through his
own employess,pmviacd that uch improvements arc not Intended or offered for aide.If,
however,Ne building or improvement ix sola within one year of completion,the owner-
builder will haw the burden of proving that he did not wild or improve for purpose of
.ale.).
I,as owner of the property,am exclusively contracting with licensed conuacmrs m
n Icon the prnjca(Sec.7lW.Business and Professions Chde:)The Contractor's Li-
m law does not apply to an owner of property who builds or improves thereon,and
who convects for such projects with a contagror(s)licensed pursuant to the Contractors
License La ..
El I am exempt order See I,' (� www aB&�aP�C births
on
Owner s/� WV /�Ir/'
KER'S COMPENSATI DECLARATION
I hereby Mo.under ped.iy err perjury oro of the following declarations:
r I hats and will maintain a Cenificare of Consenun self-,mum for Worker,Compeer- i
action.az provided for by Section 3701 of the labor Code,for the performance of the
work for which this permit is issued.
p 1 have and will maintain Worker's Compensation Insurance,as required by Section
3710 of the Ichor Code,for Use performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Comer. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if me permit is Intone hundred dollars($100)
or IcssJ
I certify that in the performance of the work for which this Permit is issued.I shall net
employ any pargen in any manner so as to become subjeet to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ceniticare of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
OO forthwith comply with such pmviumo,Nis permit shall be damod revoked,
PM CONSTRUCTION LENDING AGENCY
[—� I hereby affirm Nat here is a construction lending agency for the performance of
IX F�.r the work(nr which this permit is issued see.3097,Civ.C.)
4 Q Lender'.Name
z Lcndcr'a Address
V 0 1 certify that 1 have read this application and sure that the above information is
D., P correct.l agree m comply with all city and county ordinances and sum laws relating.
0 V abovengentioned ir,Koyhereby awhorirsmpresematives of his city mentor upon lM
r {kt .hove-mentioned propane for inspection purposes.
We)agmen m save,indemnify and keep hay in an the City o Cupertino against
U Z inconses fragments,chs.ma expenses thisPermit. may in any why acc.e.gainer said City
CJz Aconsequence of thegrantingof this permit. /
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Ignaturc ofApplic HAZARDOUS MATERIALS DISCLOSURE Dare T,Pe of Roof
Will me applicant or future building occupant store or handle W and ous mmerial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety -
cnae.seednazss3x'n All roofs shall be inspected prior to any roofing material being installed.
p Yce
Will he applicant ontura Wilding Occupant usecyttiprocal to devicca which If a roof is installed without first obtaining an inspection, I agree to remove
emit haxerdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dixtri.! sw
[I Yea R9f4n
1 haveread heh,Smdus 25505,23533re.entsunder Chapmr tiff buildinr-
nia Health&Safety Cade,Sammshat it i 2my r sod 25534.1 undersand e O carr building
doesnotents whichmua.nam.that itismyree of.iCeityicte nobly the Occurrent hl he
requirements which mustbemet ph to issuance afa Certificate of tic panty. nature Of Applicant Date
L V//// IXLI Gyr/
wriera�lhoriedasnt Dare All roof coverings to be Class "B" or better