02090053 (2) CIBU
BUILDING DIIVC�ISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10341 PHAR LAP DR CONDITIONED AIR 02090053
An 6 IEGEORGE B JR AND ALICE A 1701 LITTLE ORCHARD ST APPLICAMO YA/ L002
PHONE: (4 0 8) 2 91-2 2 2 0 SANITARY NO. CONTROL NO.
EO O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w C BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
y Ihemb firm that or Chat 9 g Jobb ription
Ya Provisions ver ad.1
CHANGE FURANCE & A�
F set with Sm11ar0 and
of Division Jaf the Business and Professions Code.dna mylittnx
S 7 in full fora unJ eRcn.
U DatContractor
enu uClass Lic.tr
MlicARCHITECT'S DECLARATION
uo
1 understand my plans shall be used as public records
of p O Licensed Professional
OWNER-BUILDER DECLARATION
y I hereby of Tin that I am exempt from the Contractor's License Law for the
C Z following reason.(Section]031.5.Business and Professions Cade:Any city or county $6750
F x❑ which requires a permit to construct.alter,improve,demolish,or repair any structure
le
63Po...prior to its issuance,also requires the applicant far such Permit o rile a signed statement- Hpaa pp1�qn r�AA aavy -- --" ---V ---- - -
-
tbutLgi;liornmapursuanttdghcprovisionsoftheContractorsLicenseLaw(ChaperY v_• , „ ,32Qrna1(]+yy�j'kpayalY4« �• Valuation
"a"a ¢ing with Sc4ion,7000)of Division J of the Business load Professions Code) '✓,_,Za ; . 2262 l..d. a.
or that fie is exempt nc�refmrn end the basis for she alleie4 eiempsion.Any violation 1
-of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalry-
1ornm mare than five hundred daxvrs x500). 301ARNXgMlgM PLUMB INc,wi'%o Occupancy Type
01,as owner of the pmpeny,ormyemployees with wages astheir solecompensatlA
an, 303 - ROUGH MECHANI L
willdo'the'work.and he sbucane'is oaYlmmnded'or offered'for'solic(sec:7044!' - 3.04 — ROUGH E I b ctlons'-”` `t:
;Busines,and Professions Cade:The Contractor's License Law does not apply to an
owner of property Who Wild or improves thereat,and who does such work himself 505 - FINAL ELECTRICAY,
or offered
h his awn Wwmccps.a budded that such improvements wi not intendedyear
or
'.ogsaa dr all.If.nsw=ever,the badain t ts aDla wirni�ons �r '— ---_._.---_—--....... --
s v fiat o .
Compli theb Id will have theWrdc fp proving d❑not Wild or f
ropy r prpos r l ) 508 - FINAL MECHANICAL
r as owner of prexclusively contractingWith uJConnaaonm
construct the pmjm(Sm.70Lt,Business d Professions Coade) 9t self rt :I•.tt ,
The Conuanor's Lf
License Law does not apply to an awncr of property who builds or improves thereon,
_ and whocontracts.for.such projects"with.a.coatranur(s).licutrad.pursuant to. .__ . .... _. __- ......._._.._._............ _ ....... .._._......._..__... ____......_._._
Commcmr's Licrnsc lsw, ,.,\.c-s I ip
-'. ❑I on exempt under See.,, ., ,B&PC for reason .Cly—�II WJ/1"h18.wk F617
_ O nl �" - - ,c
_ �f 'c -WO. Oc'Oml -ta TION DECLARATION q q
) thereby vf0rat under penalty of perjury..mr,oftihe folio ing declarations: SEP 1 Q [o OC
❑ I have'and will'arrimain- Ceriifficnk of Cm xma"rt-self-imare for Worker's BUILDING Compensation, as:provided-for by Section 37W of the Labor Code, for the IDUILDING
_ 'perfo mantt orthe'stock fur wnich this permit is .,
issued1
11_ - ❑1111 Ifni'will mainam Worker%Compenwtion Imi runes.m required by Section
J7uf1 of the Labor Codc,for the performance of the w.W for which this permit is
.edu . In sac caerand Poy u W dMyW kers Coptnmn
Cane ' t. { 1•( t- D't 1 •'f PnbcY No'. Y♦♦.v. f.., �t , t t •'3°r {T ) s�1l.1.1I t,1
It
I' {CERTIFICATION OF EXEMPTION FROM WORKERS I,t.11i5 isv.{�} )(y •NI s.•. `S1e 2.3 1,Q:
COMPENSATION INSURANCE " °''' f ___. __.._...__._.-_
,,,..,......r.,a, ..... ,_.._ -�_,.,-.-_. ._..�11,1.....r. __-__ .___._._-_...__.._.________._.__.-___—.------------
-1.1
_ _ -_•I'r"(This mctIon rind nor W uvitplaed if the permit is for one hundred dollars
(S 100)or less(,
1cnmf'th Y'as she ! f the work ft- hth!�nnath t suet I
fsilall t P�Y YR � �inin t(of,
t 1M1 Wokrs �� •-'. I I ''I IQ
Coop t C .o1C lfm
APP(cane �i'_� - .- _ .. .. . . - ` ......
a OQ{iJ' E&0?tPPLICMOT11L after makingNis,C<nfcmof Exemption,you shoI,, - - •I
We oubjett to the Workef Compe . n p ns,f L Code you moa
Q Q fndh rh c mply with such p nz nrih m
pct t hall bee dramed im.kcd.
14 fry I ' r CONSTRUCIIONLENDINGAGENCY ' ' _ _ u. f" N + ❑_-- _
f hdework for 'rKi'cmh.s,.l•h.••se•p.ar nt is issued
(aSec' 3M)"d]'
Civ.
g C)
- rs Nam ` .
IXmhr'aAadreisi
V O co1 nlfy th 11 W ad sh app(lc t d sot that th W f lion¢
correct.l agree to comply with all city and county ordinances and state laws relating
Q.V 3t-building construction,and hereby autuiriec repmaenmrives of this city to enter upon
r�_W ahe
above mentioned
pmpcny for inspection purposes.•,
+ F G 'fWcl aircesosaJe:indemnlfyatd keep hannlec the City of Cupertino aguinss
-VJ liabilities,judgments,cos)s and expenses which may in any any accme against said
'% City in Comeyuenm of the granting of mi
this pert. "
:APPLICANT UNDERSTANDS' DILL COMPLY WIYUAlL NON-POINT "
-_ _ SO RC OCATIONS.., 9;;, _m Issued by; Date
Sol Appli ilCommew,; Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
WW1 the ypueam t f rebuldmg c pant stmt handl harmddam
s ar ial Type Of.Roof . .. . v - - , r --. - •.
�a def ed by the Cupertino Murficipal Cwk CM1 pt r 9.12.and the Health and Safety
Code Sction 25532(ul ,a}rq ' . •,.'tLY J e (-l' it ^rl '�: .• - - -.�� .
❑Yes't y�'N ,^v3. , `_All roofs shall be inspected.prior_to.any roofing"material being installed..----. ._._.__
` Will the, ppl r (t W Id g occupant use equipment devices whim' If a roof is installled'without first obtaining an inspection,'(lagree'to'remove
emn hvrardi s uair comate nants as defined by the Buy Arca Air Quality Management
District? I D all new materials for inspection.,Applicant understands__and will comply.with _
❑r l all non-point source regulanons ._•ti.,,..
I h Health
Safety
Lnwa e. me¢n,2 equ rements undo Chapter 695 of the I I
California He611h&Safety Cada.Sections 35505.8533 and 25534.I understand that
'-
If the building does not currently have umwnr,that it is my P Y Y
nsibilir romnif she, ,
011 tnr oPnce requirements which must he mss prim rt-insuancc of a CeniOcarc of
r' ad ancr:
9 Si nature of A Date
ate
it,or euNorized agent."{ Date All roof coverings to be Class ","Bor better`,
-.• r
,.;;, . .,t.,,...,•,.•,M1a..-. .... . ._.. _ .. . . .. OFFICE