01070110 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: -
BUILDING ADDRESS: PERMIT NO.
1180 CRESTLINE DR A PERFECT CLIMATE 01070110
SUB DATE
"MYDINE 10570 S DEANZA BLVD A07/23/2001
' PHONE: (408) 861-9545 SANITARY NO, CONTROL NO.
q Q ZU ARCHITECTIENGINEER: BUILDING PERMIT INFO
kL"ce— BLDG ELECT PLUMB EC 1
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`9 LICENSED CONTRACTOR'S DECLARATION Job Description
ZO Z in o I hereby affirm that I am licensed under provisions of Chapter 9(commencing
p„CJ with Section 7011OWDisisiPn3uf the easmeasana Plateau...Code a ad my license A/C ADD ON.
is mraurnreeand I (HVAC)
ae,a Licenu Clas a Lu,#_
O e.U Date Cuntmctor
t'�3 u.Fn ARCHITECT'S DECLAR ION
INO g 1 understand my plans shall he used s public records
Is. O O Licensed Pndessi...I
OWNER-BUILDER DECLARATION
I hereby M.that I am exempt from the Contractor's License law for the
H
?G following reaction.(Section]o3L5.Business and Professions Code:Any city structure
tslurry-
which
cture
wh ch equ re. permit t consumer. her improve demolish, repair y o t re
a.3°—° ”dh he os s. c 1 9 pr ppi cu in for such rami a is g w(Chaptert t m. - - ati _
than nwith a a-slier visionions of ihfineBusin L . La .. 9 Sq.-Ft. F 10 rea�.-
(� - agePmrersamenae) fir "•. -> ,,.. >:!t ' >1�'^„ .. -. Valuation ...
megwitht thi 7Biand the
i4. t 0
or that he 7 3 E5 b th y, rade ani the basis for the objects
he efdarrm 1.Any violation - '"
- of Section a In. oma handled
doll fora permit subjems the apPlicam m a civil penalty
.of not mere man Eve nnnarea annars($cum. APN Number '
i.,... Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation,
"will do thework,and the structure
ir e 19 not intended or offered oSale(Sm.
But s and Profession,
r . ode:TheContractor',License Law does apply to an
304 — ROUGH EIffiq1TR3 GAllaCtlonsl' r '
ow ner of property Who builds l vesthereon,andwh does a n workh If 505 — FINAL ELECTRICAL
or m gh his n empl y .presided that such improvements t tendedor
' err N f al If:howeve ifi bu Iding or improvement old in rte r f '5 0 8 _-FINA MECHANI CAL -I: --% ---
.inflation.thenamer,hildr,svill heoe,he burden f,.,i.gthlt h d d rainuildcur ;
improve for purpose of 1 )
O 1 er. f me Pmpcny,am exclus ly contracting with licensetract s t _ ... _ _._ _ Y} -.
construct the project(Sec Llad Business and Professions CWe:)no Contractor's
_
C o t _..__ . .. -.___. ,....... . .-. __. _ .. ....
/ Q
II.
n
._rLicense Law aces not apply to an owner of furniamy who builds p thereon. x.und hLets G h.projects wth c tr tursl a.pursuant i the
Contractorsice
a. r ' B&PCf the erP S
-
"i •s;t /
.. - Owner, - Date .}...
WORKER'S COMPENSA"f1pN DF.CLAIiATION
i. 1 hereby affirm under pevah of
perjuoofthefollowingdecimations:yry —
❑ 1 hove-and'wdV1 riintain a'Ceniflc5ie W Conseni to self-insure for Worker's
_ Compensation:-a.-provided for by-Sectiom 37W of me labor Cade. for the
- - - 'performance of the work for which this permit is issued..
❑I h sand will ren to Worker's Comprosadim ir,mmnae,as required by Section
3700 of the Labor Code,for the ponfinarancte of the work fo -which this pc mn is
issued My W rl:ers Co Pc sii 1 Aum m e��mlrP//ol'y!,�---brre,,
Carol jcy No I�"J 46VK U line d I .. > .m_ v t/d IT.t I P . .,�.._.......
ERIIfl ATION OF EXEMPTION FROM WORKPRS'l "a s `ice ''' -r
-'COMPENSATION INSURANCE"_-"
iso (This Secimm need not be'compleied i(me permu sfor onehuntlred dollars it 'fs l
SIN) less;) ^
1 c n fy tlui'in the peAorma o(me `ok(r-which this liecrit IS issued;I
shall trot employ any perron m trey manner so as to hedome sub3ect m the Woikeii - •t'ej'�'i'
Co pensat on Laws of C I f Date' "" ,
^NOTICETOAPPLICANT'If.after Compsmetal map Certificate of Exemption.you you
Q Obecome au amply the K'orke?s Compensatiah provisions bf the Labor Cade,you moa
7arth th co ply with h p 'xions or this permithall be deemed rooked. ,
.EaWr.-;.ytiQ I�'s•di sSTRUCTI'ONILEN_D_N..'G. X'GLN.CCY
Ili by Brmthat m construction ag )
Yfor the performance ofth , rkf which this permit seed J ] C
el
.... __-.. .. ._.._.... _.. .-. .._ .._... .__. :. - _. ''.t!_1.
Zen).z Led Address.. .
d'•,
V 1 coldly that I have raind,hi,application aiod some that the above mformaion is
Gasp Fy 'correct.I agree to comply with all city motcounty ordinances and slate Ivws relating
to building construction,and hereby authorise representatives of this city to enter upon
.the b e h -edp penyf ills" pry .. _
[.i.0. (We) gre m ndlamh`Y and keep s.ineCty f Cupertino against
Z Imb I sees I dg nos,c is ad expense which m y n any ay,ace again t wid
City in c .-y ce of gr ni g f this permit.
APPLIeANf UNDERSTANDS AND WILT,COMPLY WITHALL ON-P IiNT
�''lJA W sri� ��rl� P� Issued by: Date
&ISelflure cifAppF.InlCoo , "+'"' ' at Re-roofs
" HAZARDOUS MATERIALS DISCLOSURE t
'.
Will m8iippliewitinhifirm hu'mi a air p r t re r natal nariNo tm;m. •'I)rpe.of Roof_ . . . . .
as defined by the C,veniw Mumnpel Cad Chapter 9 12 and the Health and Safety'
Code Scon255321a1 s1
[7 Ye I,',
f t. - o - r;, .,.a_ 1• ta) , 1, iii . •� s. :qi
zI 's ' All roofs,shall be inspected prior.to.any roofing.material.being.ins I,lled.
) � s
d wnm ppr i fuweb Idingoccupamuseeq pate t a geswmrn' If a roof is installed'without first obtaining an'inspection';tIdgree•tti remove
e.it h a coo m dined by ByAreaAlQ Ity Manage o
rn t t all new materials for,inspection."Applicant understands and will,comply_with.,
t� oY •�'` P:';' " "all non-point source regulations.;,,, ', •,,,q. „
hove read the hauNo na mmeoialx requirements ondec Chapter'6.95 ofthe
'&1domiv Health'&Safety Code.Sections 25505.25533 and 25534,1 undiam and that
i the hu la g don.'not cooly h {en m th t t
is my responsibility to t fy the'
;dlfP t hM1 rcqui m n' h'muatb tp" to ii neor Ccn'lict of
Occ pan y ' .• . ,.., .' '
p/ / Signature of Applicant Date
n r ra o :ed m 0 soak/. All roof coverings to be Class`B"or better, 1,
OFFICE . .. ... . .. . ... . . ..'- - -'- - -