08020174BUILDING DIVISION
BUILDINr� FS PERMIT NO.
lUUb5 ADRIANA AVE DANIEL MACKEY CONSTRUCTION 08020174
OWNER'S NAME: INC PERMIT LSSUEDATE
2593 HEBRON .AVE '02/26/2008
PHONE SANITARY NO. CONTROL NO.
(408)274-6799
ARCHITECT/ENGINEIiR: ... BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
p o LICENSED CONTRACTOR'S DECLARATION
U E I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
�.m with Section 7000) of Division 3 of the Business and Professions Code, and my license is
y in full form and eff
IgZ License CI Mi. H 14(L- LJc. #
F, Date Contractor:ti
ARCHITECrS D ON
I undermod my plans shall be used as public records
o, V
O y Licensed Professional
y 5 OWNER -BUILDER DECLARATION
1 hereby &firm that 1 am exempt from the Contractors License Law for the
in Op� following maven. (Section 70313, Business and Professions Code: Any city or county
$_ li which requires a permit to construct, alter. improve, demolish, or repair any structure.
Z Prior to its issuance, also requires the applicant for such permit to file a signed statement
_ C that he is licensed pursuant to the provisions of the Contractor's License Lew (Chapter 9
F- $ (commencing with Section 7000) 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 mom than five hundred dollars (M).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Busincsa
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 tbmgb his
own employar, provided that such improvements ate not intended or offered for ssle 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 propeny, uo exclusively contracting with Licensed contractors to
construct the project (Sec 7094, Business and Professions Code:) The Comiacmes Li-
cense Law dors not appy to an owner of property who builds or improves thereon. and.
who contract% for such projects with a cont actors) licensed pursuant to the Contractors
Liana- Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Due
WORKERS COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations
❑ I hsve and will maintain aCertifiate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issrod.
My Workers Compensation Insurance carrier and Policy number am:
Canier:`f� f; i ri PolicyNo.: %13 (SOI 523J
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars (5100)
or less.)
I anify that in the performance of the work for which this permit is issued, l shall bot
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California Due
Applicant
NOTICE TO APPLICANT: IL after malting this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Libor Code, you rust
z forthwith comply with such provisions or this pcanit shall be decmed revoked.
z O CONSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a construction lending agency far the performance of
lye > the work for which this permit is issued (Sec. 3097, Civ, C.)
W Q Lenders Name
�D z Lenders Address
U Q 1 certify that I have read this application and state that the above information is
LT. comers I agree to comply with all city and county ordinances and state laws relating to
OU building construction, and hereby aurhorim representatives of this city to rater upon the
W above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
HcA fiabilities, judgments, costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit
r-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG TIONS. 7-4L LV
Siknaturc o"'il ApplicanUConuactor Dare
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Conk, Section 25532(x)?
❑ Yes Oko
Will the applicant or future building occupant use equipment or dcviaa which
emit hazardous air conraminar u defined by the Bay Area Air Quality Management
District?
❑ Yes
I have read the hazardous materials requuemcnt%underChapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant that It is my responsibility m notify thc o=upant of the
require to issuance of a Certificate of ry
n-%nn.ed . rent Date
Job Description
REPR TERMITE DMG,REPLC WNDWS,NEW STUCCO(ENTIRE
HSE)
Ft. Floor Area
$35000
3262003OqNumber
Required Inspections
Issued by:
Re -roofs
Type of Roof.
Type
Date -' z 9-
2—
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.
Signature of Applicant Date
All roof coverings to be Class "B" or better