05030135 CITY OF CUPERTINO9
PERMIT .,. .....z ,.........e;rw Y..INFORMaATa ION+`
BUILDING DIVISION 'IR '.'
'
BUILDING ADDRESS: DAHL PLUMBING CO, JOHN F PE "'15030135
q7 MnPTMPRQ0K SQ
ER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
O
ARCHITECTrENGINEER: - BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'S DECLARATION
�L mF 1 bemby affirm that I am licensed under provision of Chapter 9(commencing Job Description
SZ�y with Section 7OXpof Division 3oftW Businusend Profession Cadc,md my license is
�qi u«lmAsset, BcNe_t Ix.. nL,"/()9 REPLACE FURNACE & ADD A/C
L~� Date 5— fd—req- Conlsanor�—r +�
qq ARCHITECTS DECLARATION
W u 1 understand my plans shall W used as Public ranrds
o n/
. oy Licensed Professionalt
OWNER-BUILDER m MeC.. cite '1
0 0 ON
I hcehy.(Seco on 1 am exempt from d r femmosrCc License Lew for IW e�l+�s�Lr
3:00 following rtuoa Permian RBusiness and improve,
dcN.m Codc:Any oily or county
$'n which eyuies a permit re uir construct.;Malter improve,demolish,ri repair any swment ') a
Fzi mark its issuance.also requires;lW applicant for such Permit in Gla aaignrdaummmt
FFmm< (comme licensed Pursuant 7M)of
Divisio of the Conuines iLicemclaw(Code)9 Sq. Ft. Floor Area I II V4163t10❑
e(F$ mammen...pt umfond andM Division3 nftheegid Businessxaand
pt Professions Cade)or
— Natio is 31.5 b nary.ppm and the beers for the alleged exemption.Any violation of
Section Man
five
hundred
red dont for•permit subjects Ne applicant a civil penalty of V
not more than Gw n.naea donate(ssro). 3 JAS-�N�C4)O U(/� 066iI ptotic Type
1,uowseeofthepropmy.mmyemPloyeuwithwageu Nabmkeamxnsstkn,
will do the work,and Ne structure u not intended oraRered rat sale(Sec.7044,Business
and Profession Cade:The Contractor's License law does fiat apply mart owner of Required Inspections
pmpeny who Wildsorimprovu themon.and whodoessuch work hmselfor through his
own employees,provided that such improvements are not intended oroBerW Iterate.If.
however,Ne building or improvement la sold within one year of completion,Ne owner-
builde,will haus the Wrdco of proving Nat be did out Wild or improve for purpose of
sale.).
❑1,as owner of Ne property.am exclusively contracting with licensed connectors to
construct the Project(Sec.7064.Business and Professions Cade:)The Comstcmfa Li.
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a conoacmKs)licensed pursuant in the Contractors
License Law.
❑I am exempt under Sec. ,B&P C for dru reamn
nee Dale
WORKERS COMPENSATION DECLARATION -
1 hereby affon under penalty or perjury one of the following declarations:
I haw and will maintain a Certificate of Consent to self-insure for Workers Coolies.
ration,as pmvided for by Section 3700 of the labor Code,for the performance of the
work foe which Nis tenni,is issued.
I have and will maintain Worker's Comperei Insurance,as required by Section
3700of the labor Code,for Ne performance of the work for which this pemtit is issued.
My Worker's Compemmon Insurance tarsier and Policy number ae:
Canicr. lQ Policy No.: OO/32R(
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu mcbon seed not kcamplemd if the permit Is stone hundred dollars(1100)
Icse.)
1 emGfy that in the performance of the work for which this Permit u issued,l shall not
employ any person in any manner se u to become subject o the Workers'Compensation
Laws of California.Date
Applicmr
NOTICE TO APPLICANT:IL after making this Ccnifcme of Exemption,you ahuuld
become subject to the Workers Compensation provisions of Ne labor Code,you muss
.Jz forthwith comply with such provisions or this Permit shall be deemed revoked.
Z O CONMUMON LENDING AGENCY
[-+ 1 hereby affirm WTI then is a construction lending agency for the performance of
C Ne work for which this Permit is issued(Sec.3099,Civ,C.)
QLen&ea Name
z Lenders Add.
[)Q I certify that I have mad this application and sink that the stow information mincing to
lI.H building I Agreeonsh m comply with all city and county oNinanes and sum laws elating e
V tuildingcomtmctiro and hereby authorize u¢oses. vas of this city to crime upon d¢
F{31 shove-miumme o property for Inspection p Purposes.
9L (We)ogee to save,indemnify and keep harmless the City of Cupertino against
fA
liabilities judgments.costs and expemu which may in my way accmc against said City �.
C)vZ A PLICANT ofthegranting of this per mit. OJ
^ APPLICANT UNDEReT DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
S U 7
5���" 0S Re-roofs
bignaMolApplienuCcuffili Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding esupanl afore or handle Iwaseous material
as defined by Ne Cotentin.Municipal Codc,Chapter 9.13,and the Health and eafe,y
c,Section l553I(a)?
❑Seely `�No All roofs shall be inspected prior to any roofing material being 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
h haeardous air mmaminams u defined by the Bay Area Air Quality Management all new materials for inspection.
iWiCl?
❑Yes SyN.
1 haw mad the huaNtmr materials mquimments under Chapter 6.95 of Ne Califer.
nix Health&SafctyCutlr,Secdom 25X)5.25533 and 25534.1 uMcrsund that it lbe Wilding
dam not e m tiny ha rmnam,this it u my responsibility In notify the occupant of the
)Llai nkawh bemmpn.etu anbror.Certifies.ofOc.pmcy. Signature of Applicant Date
6s
nc Ilmnxcdagent All roof coverings to be Class"B"or better