02060008 CITY OF CUPERTINO --
BUILDING DIVISION , PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: PERMIT NO.
21641 REGNART RD ALTON AIR CONDITIONING & HTG 02060008
OWNER'S NAME: APPLICATION SUB DATE
DAVID BLIVEN 45300 INDUSTRIAL DR #4 06/03/2002
•..
PHONE: SANITARY NO. CONTROL NO.
1 (510) 490-5655
0,-6 ARCHITECT ENGINEER: BUILDING PERMIT INFO
❑❑ BLDG ELECT PLUMB MECH
day •S •-. ,,:'•.: ,•�',-;.�,"."-_ '.
-:,':.LICENSED CONTRACTOR'S DECLARATION - Job Description
OZ Ih by affirm that l am licensed der provisions of Chapter 9(commencing �,tI
F=t's withSation700rBofDivision3ofoeBus a:andPmmsgmna�ydcpitamyPortae INSTALL A/C �'���E®
cl pl- is in(all a an Rttt tJjs Y /
C z a License [iC.N 1
to Date'' r� Cf'S DEC< TIO - Q
L y g I uWerstvrd my plans shall be uud as public me. APR O ata 200
00
Licensed Professional OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contactors License Law for the
BUILDING
tea following reason.ISeeuon 7031.5,Business and Professions Code:Any city or county'
Y Z O which rtgmm a perm t to construct.alter pin a demolish.or repair any structure $2900
3Is ..pnorto its issuance,alrequires the Applicant finch Permit to file a signed statement
Ntht humLlceresed pars tt the provisionsfin C t tore Littre law(Ch pt 9 F[ pa,1Q OC fey say; r f Valuation
nimcmd'i wth,Secii ,7000)of Division J of the❑ mess and Professons Cwkl +[J�'; 1.3,JS(JL ,0 4•,+V Si.lMn '^aA fl iii
or that he 14 evemin therefrom and one bass for the atliged emorptioo.Any violation a'
-.(Section 903 L3 by arty apptican for v permit suM1jecu the vpplicanno v rivil Pendry TyP
of no,mom than five hundred dol)am S50% API tt�� TTTD������� "' •^ Occupancye
304 - R�UGH EL' E' CTRICALa
O
L',
us owner of the property,at my employees with wages as their sale compensation,
.wAI-do-the'work;-add'the-stmende isnot intended or offered for sale'(Sec-7U41,
'Budrm s and Professions Code.The Contractor's License Law does not apply to an 505 - F I NAL E1SL^CITSI A1TVRctIODS - `
owner of property Who builds or improves thereon,and who does such work himulf
or th ugh h w employees,provided that such p mens am not intended or t
lofficed for s the bu of Prove nen is sold wthn nneYar of ,+, tL.
completion,the owner bmWer will haveethe burden of proving that he did not build or
improvgor purpou.(tale.).
❑or, owner o(Ihe property.am exclusively contracting with licenud convacton[o .,i.t.,t';.0
o duct the project(Sec .7044,Business and Profexsi0ne Code)The Contacror's
'License Logr does not apply to an owner of progeny who Wilds or unproven thereon,
r,
c ' a dniamori License
such,projecu,wth,a cantanm(s),Itcemed,pursuan to the_
,r 'C - Law.
p oder sec.' rr.•';"B&PCfonhis rwson �,i11...... .. '.d.',
:... . ❑tem exempt :.. ,.•e ,.. . .•.: ,... ..•.. i :..
n
Dome
W RKE)�PENSATION DECLARATION
,�• -I hereby affirm under permlty of pc 3 ry ne of the following declamlio ....
❑ I Wsi, nA w i,monitor,v Cehirei"eW Consent to'self-insure for Worker's
'o�i'' _ Compensation, as provided for by Section 3100 of the labor Code; for the
-_ performance of[tie work for which this permit is issued.
❑I have and will mAimain N'oder s Cminkmvmn
iion Imuce.as segoired by Sermon
1700'of the Labor Code,for rhe peko6nanhbf the'Ilmic for which this permit is
issued,My Uri C ,rdaii.o Insurance came,.and Polcy .in arc
� - s P,..v - th
b (1 CLRTIPICATION OF E%EMITIgN FROM WORKERS j' 1", i;- ,- +1- Y1 JA i)I
...,. ! .. ,. COMPENSATION SURANCE y. ...,.,, . .._. _....,,.. .._- __..:....,._ '....... "-_ ..., .,.....
' t(Thm cec[i0n need no[be completed if the Permit is for one hundredd011an t ' ' `I'"''t -
11 100)or leu,l .
Y is J 1
I tend Ib i the Per f romance e of[h work f which this permit is ,
'hvllnot en l 'm n in in rete s W'kers Gr.:a .1 ;i:lipfJ: - tf
Apmpcnwuon Laws of Calr[om o.Dare- -'
NOTiceoT PLIC
;NOTICE TO APo the Worker's
after Compensation
this Cenificm f the
Eicmplion:,ycni mind _
hecomesubject lothe Inch
Cbmpenwvon Pormit oas of thetabor Cole,you'mun
Q Q fonitwith mmply'witti such provisions unhis permit shall be deemed revoked. 1
.r )( '.'CONSTRUCTION LENDING AGENCY ' -"''`" - 'I1 1 "'•'
1 hereby ano Jut there is a con n I A -g agency(o th peRomuanc
eokf - hch thisParma (S issued c 409] Ct C)
te /N
LensN s
� z Lch J 4 Add. ;s _ t L
V �, 1 can fy[ha I have read th a xppl cm on and stoic that[he above information is
eomn.;l agme to comply�+vi,h oil city and gionty ordinances and state Ivws misting
f.1 m h IJ g m ci n a J h by uth n[ repremoolflors.hh
rhe b m d p p ty f m Pure s _ city enter
nmr upon
(W lag em indemnify and keep hamless the Cityodf Cupemno against
(Z) liabilities.Pdg a u,ImmJ expenses
which
�
may in any way ac<sue against said
V.z ci[Ym< q ee of theg in of 0apermn '
Pf ICAN'T,L c AND IViLL COMPLY WITH ALr UON'FOYNT ay
h d Rc Ikt: m ,pi's ,t�l. . Issued by: ' Date
Signat pp fiilr mcantractor "' ;Y:. / -, ",Daze. Re-roofs
,• HAZARDOUS MATERIALS DISCLOSURE
01 [urc.11 Fatan pat furor handle huallous ten[nal Type of Roof
esJfined bthe Cuen Mail is pa J Chpmr 91 and theH,lth JSfr, '
on
Code Sectio 25$7t a) r u o f b a I Y f i• 7 I «.i' ( i',syl ra i.r .. . ,
❑Yes U. r ✓ - n -
u, All roofs shall be inspected prior_to any rooffng,matenal,being instilled
, t W Rtheapplicanto future bWildingoccupantuseintuitional rdevices which If a roof is installed without first obtaining an inspecnori,'I agree to remove
emit hazardous en t nms (s d d by the Bay A'e Ail Quality Management
District? all new-mateilials for inspection. Applicant understands and will comply,with_
alCnon-point sourceYe ulanons
I h Health
&Safety
hazardous e iopals ray rremenu under Chapter omte of the
if theOrnia Health s of Code,have
am mount,
that
t itis and 25574 1 of to
of that
"t the mg,m not currently whiCvea mnbe met priosmymsponsiofa to notify the
occup'ani[o ere vire s whi<h'mui[h me[pnono issuance o(p Cenifcate of '
- i. t -
Signature of Applicant _. .-,_ -- Date _
o rat, .ee,get - i., ^pats; f All roof coverings to be Class B"or better
-- __. ._ .•_:. . . -OFFICE. . .