03110112 CITY OF CUPERTINO ' '°` s'^
BUILDING DIVISION PERT* CONTRACTQR�INFQRM .. QN
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BUILDING ADDRESS: PERMIT N993 110 112
6379 ATHERWOOD
NEWS NAME: PERMITI SUEDATE
ARD JENSEN — 11/20/2003
NE:
SANITARY NO. CONTROL NO.
A0.CHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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7p LICENSED CONTRACTOR'S DECLARATION - sM
C 1 hereby affirm Net 1 em lido.d under previsisr ion of 1 Code 9 .1See-(commencing- Job Desc � �e
_b6 With Section] )it that I a .lithe Basin aM visioniof hapmr 9 cense ply
m coram derrea �` 38'�og7 SUPPORT UNDER GURDER
Iv,
License u g
Cu were, nen c G;.:qgg-_ CONTRACTOR: BRIAN GUINA a ,l004
/ ARCHITECT-SBBAiARATIDN< iontleonand my plans mall k used ar(Mic records DECtg[�a
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Licensed hereby affirm
BUILDING I as ®� kgs
ng OWNER-BUILDER DECLARATION •eryV( L pq[�pyi�'
a 0 1 hereby o(firm on 11. exempt Dust.from the Contrafeedim Cod Liccnu law for the
.a which
awing moon. hermit t 8131.5.Busiass and improve.
chouos Code:Any city lir county
which rtquissuance.emso re uir s the akc,impww.demolish,lir repair any swarm
Z6 pilarlaslcensepaluanttodSNC isionsnI(hersuch ConpermlltoMe eoa Law IIhillerl 975
ce (commecing wJ pursuan700BofDivionsMNeCnlsinessndPrscemon(Chiller Sq.F[.Floor Area Valuate J
(commencing is axe with Section]000)of bassos f 3 of al Business and on.Any
Code)or
$
that k is exempt therefrom and Ik basis for the alleged exemption.Any violation of
Section 70315 by airy applicant for a permit subjects the applicant o a civil penally of APN Number Occupancy Type
not ream in=BK hundred d.nars(S$M. 36916010 . 00
❑ I.u Owner of the pmperty,or my employees with wages u their sole compensation,
•will do s e work and the structure is not intended or offered for sok(Sec.7W.Business
and Profeuiom Code:The Conlctelor's.Littme law docs trot apply in x
an owr of Required Inspections
property who builds or improves thereon,end who does such work himself or through his
own.nplayres,provided that such improvements are nolimended oroRered for ale.if.
however,the Wilding or improvement is cold within one yeti of comply im.the miner.
.builder will haw the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,as own.of One property,am exclusively contracting with licensed conacl.m to
convect the project(Sce.7004,Business and Professions Code:)The Conmcmr's Li.
eeose Law dors not apply to an owner of property who Wilds or improves thereon,am.
who contracts for such projects with a comtesemr(s)licensed pursuant o the Comtsac ccs
rose law,
I am exempt under Sm .B&P C for this mason
Dau
WORKER'S COMPENSATION DECLARATION
I arch,afnrm under penalty of perjury one of the fallowing declarations:
I haw and will maintain a Ccnifcare of Consent to self-insum for WorkctsCompcn-
unti m,as provided for by Section 37t10 of the faWr Cade.for the performance of the
work for which this permit is issued.
❑1 ave and will maintain Workers Compensation Insurance,as tcyuined by Section
3700 of the labor Code.for the performance of the week for which this permit is issued.
My Workers Com sanalion Insurance crier and Policy number are:
Cam.: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu vection recd not W complemd if the permit is faonc hundred dollar(Sia))
lir lets.)
1 certify that in the performance of IM work for which this permit u issued.I shall not
employany pcow
any maniKruum Wm ubjecuo tk Worit Compcmudon
Laws of Cairo an c /-7'h>
phi ant — _ a Lem
ANPp E APPLICANT:R.am,making this Certificate or Exemption,you should
bdfDMe subject to the Worker's Compensation provisions of the Labor Code,you must
O f.Mwith comply with such pnoviume or this permit shill k doomed tewked.
CONSTRUCTION LENDING AGENCY
1 kreby affirm that tar,is a coos ssurdon lending agency for the performane of
the week(us which this permit a i.W(Sec.309],Civ.C.)
0 Lender's Name
Z Lender's Address
p I curtly that 1 haw reed this application mid sure in.,the aW M kr.ormun is
curmL I agmr to comply with all city and county on inanes and state laws misting to
U building eormtruclion.and kreby ludmilme rcpmeanmives mf this City to COW upon the
t W .hove-ommiooed property for inspection pulp..,
t Oa (We)agree to ave,indemnify and kap harmless the City of Crouton against
th liabilities,jidgmcnW costs and c.pct.^.which may in any way...against said City /
I Z in mmegmne of the groming of this permit.
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEI�ULAT?ONS.�v /
O.YJg,(gs,sJ e(Z[<'''"e,- o�–d Re-roofs
ad
Sig verso[Appli...ulZmancmr Dau
HAZARDOUS MATERIALS DISCL URE Type of Roof
Will the appimmt or fuum Wilding ucupam atom or handle huaidous mavrial
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Hcalth and Safely
ale.Section 23532a)1
❑Yes �No All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future Wilding Occupant use a If a roof is installed without first obtainingan inspection,I agree to remove
PP 8equipment or devices which P g
..it Wrardnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Oyu �No
I have mW the h rardous materials requirements under Chapter 6.95 of the Califo,
not Health&Safety Cock,See..25515.25533 and 25530.1 rndcsaand thin if tk Wilding
dos nl ct n utly hest a unans tat it u my respomibility to notify the Necupr nt or de
requirements which m,n he real prior t issuance,of a Ccrdficauo Occuancy. Signature of Applicant Date
Owaauboricdagcnt Dere All roof coverings to be Class "B"or better
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