07090074BUILDING DIVISION
VES DR
PERMrr NO.
GOLDEN GATE MECHANICAL INC 07090074
OWNER'S NAME:
YOUNG MEN S CHRISTIAN ASSOC 1793 LAFAYETTE ST
ovnntRl'c'
ARCHITECTJENGMER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
vith Section 70D0) of Division 3 of the Business and .rofessiurrb Code, an
n full force and effe L
rcensc Clara Lic. #
)ate % Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
.icensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signet) statement
that he is licensed pursuant to the provisions of the Contractor's license law (Chapter 9
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
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 to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner ofthe property, or my employers with wages as their sole compensation,
will do the work, and the structure is not intended or offered forsale (See.7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li -
cease Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contracior(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worke s Compensation//11��tsurraancce carrier an Policy number ate:
Carrier. �� '<� �[./��
COMPENSATION7NSURANCE
(This section need not he completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date - - -
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Name -
Under's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cos and expenses which may in anyway accrue against said City
in consequence of the nting of this permit,
APPLICA N STANDS AND WILL COMPLY WITH ALL NO -POINT
SOURC ONS.
Sig at rc pplicantlContractor D
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantor future bull 'ng occupantstore orhandlc hazardous material
as defined by the Cupertin71C.,
Muni1 Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes
Will theapplicant or future building occupant use equipment or devices which
emit hazardous air contaminants as def by the Bay Area Air Quality Management
District?
Yes 91f.
(408)246-3355
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
T.I. A.3 OCCUPANCY— REPLACE EXSTNG AC
10/05/07 PLAN COPIES (THEY LOST PLANS) $55.70
ADDED TO FEES.
Sq. Ft. Floor Area
32632039MbTNumber
Issued by:
of Roof
$56268
Required Inspections
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
1 have mad the rdnus materials requirements under Chapter 6.95 of the Califor-
nia Hcal h & Safety C , Secdons 25505,25533 and 25534.1 understand thatif the building
does not currently c a tenant that it is my responsibility to notify the upant of the - - —
require must met prior to issuance of a Ccr ificatc of Ck an ..> Signature of Applicant Date
OwZr MaKharizedagent Date All roof coverings to be Class "B" or better