05010051 CITY OF CUPEWFINO
BUILDING DIVISION PERMIT CONT=RACTOR INFOI2MATIQN
JWNER'S
Ol �RESS: MASTER BUILDER & CONSTRACT KaMITNo05010051
NAME: PERMrr MUE DATE
LITTLE MUSTARD 01107/2005
ONE: SANITARY NO. CONTROL NO,
(408) 866-0999
ARCIII ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
lOo LICENSED CONrRACrOR'SDECLARATION JobDescri tion O O O
�wp 1 hereby of m Thal1 am Iisen¢d under pmvisionUrfqmde, 9(commencing p
DU ou with en if Division I ma fthesed nde andP ,m,9m 1
lca °CfC y rota REVISION--IN HOUSE USE ONLY
q= Date Class _ Lie.
;ro
Date canlracto .� N0 NEW PERMIT ISSUED/ORIG. 404080235
LQ� AR {Ilk usS
C W U L rsanJ my P.....all be used as public ret x�
eLLr Licensed Pmfcssional
OWNER-BUILDER DECLARATION
<I 1 hereby affirm that I am exempt from the Contractor's License Law for the
n O following reason.(SeeGun 71131.5,Business and Pmfe¢ioas Code:Any city of county
<m which requites a permit m Conswct,alum,impm.c,demolish,or repair any mruaum
prior to its issuance,also prepares the applicant for such Permit to file a signed statement
.xx<
that he is licensed pursuant to the parvisions of the Contractor's Limpic Law(Chapter 9 Sq. Ft. Floor Area Valuation$45'
rF0 (emarombing with Section 7(0))of Division 3n1 the Business and Professions Code)ur
2 Nat he is exempt thcmfmm and top baso for the alleged exemption.Any violation of
Section 1031.5 by any applicantfor a permit subjema de applicant W a civil penalty of APN Number Occupancy
nal mare man five hundred dollars(SSW). � P Y Type
❑L e owner of property,0r my employees with wages as their sale compensation. 32633102 . 00
will do the work,and the swcmrt is not intended or offered for sale(Sec.1044.Business
and Professions Code:The Contractor's Liceme Law dare not apply m an owner of Required Inspections
property who build&of improves thereon,and who does such work himselfor through his
own employees,provided that such improvements are not intended oroffered for sale.It. -
however,the building or improvement is said within one year of completion,the owner-
builder will have de burden of proving dal he did not Wild or improve for purpose of
aide I
1,as owner of the propenX am exclusively contracting with licensed contractors to
vuuct the project(Sec.704.Business and Professions Code:)The Contractor's Lt.
cove taw does not apply to an owner of progeny who W iIds or improve demon,and
who contracts for such ptojeca with a comanumar(s)licensed pursuanuo the Contractors
w.
pCose La
I am exempt under Sec. .B&P C for this reason \�
net Data V -
WORKER'S COMPENSATION DECLARATION
1 hereby afr"m under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate v
of Consent to sel6pp
inse for Worker'sCompen-
sation,u Provided for by Section 3100 of he labor Cade.far he performance of the
work for which this permit is issued.
C31 have and will maintain Worker's Compensation Insurance,as required by Section
3100 of do Labor Code,for de performance of the work for which this permit is issued.
My Workm's Compensalionnlnfsunsomearier and Potic tuber aa:
_ � If Nf�% Poli No., u
CERTIFICATE OF EXFMPrI FROMW R ERS'
COMPENSATION INSURANCE
(Thissectitm need nm becompe.d if the permiu is foram hundred dN1an($100)
less.)
I certify that in the perfom come,of the work for which this permit is tooted.I shall nm
employ any person in any manner or as to become subject o the Workai Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:1f,after making this Certifier,of Formation,you should
become subject to the Worker'&Compensation provisions of the labor Code,you most
.� 2 forthwith comply with such provision or this Permit shall he deemed revoked. -
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat them is a contraction lending agency for de Performan¢of
Y the work fur which this lemon is issued(Sec.3M.Civ.C.)
'Sl t7Lima,'s Name
3. Lcndcr's Address '
D 2
J 0 1 minify had I have read this application and sate dal the above information is
correct.I agree to comply with all city and county onfinances and Sam laws relating to
JU Wilding constmetion,and hereby audoria mprceentatlma of this city to enter upon the
4
above mentioned pralmay for inspection puMoma
y (Wil agae to save,indemnify and keep harmless the City of Cupertino against
p3 ImbilitieLjudgmcats,costs and oxpcnsu which may in any way accrue against mid City
j Z in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale a
SOUR 'JUDATIONS.
Re-roofs
Ignamrc of Applicam/C0 aclom Da
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hmarduus material
fined by de Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
e.Section 25531(.)? All roofs shall be inspected nor to an roofingmaterial being
❑Ye �t P P Y g installed.
I Will the applicant or fwure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nil hatmdous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
a ac
/
❑Yes 015 .
I have mad the hvallous ma trials rcquircments under .Chapter 6.95 of the Califor.
nia Heald&Safety Code.Sectiov25505.25533 and25534.lundcrsand duifde Wilding
doll not curcnlly have a tenant.da it u my rcspanihility w notify the rucuPmt of the
mqui no which Must ime,rotten,iasumaora Certificate of mupancy. Signature of Applicant Date
weer or ammaxed. eel ale All roof coverings to be Class "B"or better