04080157 CITY OF'CUPERTINO •. ""^ ", '"^,
BUILDING DIVISION PEIM, CONT UCTORANk'URIVTA N
BUILDING ADDRESS: PINEWAVE CONSTRUCTION, INC PERMIT ND04080157 .
OWNER'S NAME: PERMITLSSUEOATE
dk DER WEI CH
E: SANITARY O. C OL NO.
408 4 -
ARCHITECTIENGINEER: BUILDING PERMIT INFO
PLUMB MECH
0
upp
LICENSED CONTRACTOR'SDECLARATION JobDescripti _
Ye,F I hereby affirm the,1 am licenxed under provisions of CTapmr 9(mmmcming
`Zt� with Smtion]0(110 of Diviaion3o(thc BusimssaM ProfcsLuou Cock.arM mylicenmu
in ran mree and errec` DEMO E HOUSE
; = License Class Lic.g OCT ��`-2D04
Dam Con0acmr
ARCHITECTS DECLARATION
Iussmy plans shall buseupublic«curds
Licensed Professional _L®-I
--- . -
3 OWNER-BUILDER DECLARATION
's E 1 hereby a?rm Nal 1 am exempt from the Contractors License law for the
p O following moon.(Section 7W 1.5,Business and Professions Cade:Any city or county
K m which requires a permit m eoaswcs,alcor,improve,demolish,Or repair any someone
'tzy prior to its issuance,also squires the applicant for such Permiuo file a signed mmment .
ESC that lon is licensed pursuant to the provisions;of the Contricam's License Law(Chaincr 9 Sq. Ft. Floor Area Valu hon
(commencing with Section 70M)of Division 3 of the Business and Predictions Code)or -
y W S that he is exempt therefrom and the basis for Ne alleged exemption.Any violation ofwmsatrw,i.ran.
Stood.7031.5 by say applicant far a permit subjects the applicant 10.civil penalty of 3-rvr.TO14 l;rQ 0 Occupancy Type
not more thm five hundred dollars(S5W).
0 1,as owner of the property,in my employees with wages as their sato compensation.
will do den Work,and theamimm is notimmnded a offered for sak(Sec.7061,Business Required Inspections
and Pmfessiov License Law Code:The Contractor's Licew docs not apply m e an ownu of q p
proy
per who builds orimproves theman,and who does such work himself orthrough his
Own employees,provided thitsuch improvements art not immtuded a offered fasale.If.
however,Ne Wilding ea improvemente is sold within ane yeti of compledoo,Ne ower
.to
will haw dm Wrdof proving drat M did roa t Wild improve par
pose puase of
salt.).
m 1,as Owner of the property,am exclusively contracting with licensed contractors to
Conswct dm pmjttt(Sec.7064.Business and Pmfusioer Code:)The Conuacter's Li-
come law does not apply to an owner of property who builds or improves thereon,and -
Who contracts for wchpmjam with.centrads,(.)licensed pursue,m the Contractors - - - -.
License law. - -
El I.Catnip,under See B&P C for thismason
♦
WORKER'S MPENSATIONDEC R'A N
1 hereby affirm under penalty of perjury one of the following deeluatiov:
have and will maintain a Certificate of Coven,m self-insure fa Worker'sCompen-
eatioa,as provided for by Section 3700 of the labor Code,for Ne perfamanct of,hc
work for which this permit is issued.
rl 1 ban and will maintain Worker's Compensation boundaries,u requited by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insursnce amu and Policy number art:
Comer. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Thu section mod not In complemd if the permit is forme,hundred dollars(SIM)
or less.)
I certify test in the performance of the work for which this permit is issued.l shall out
employ anypuson in any manter in n to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,a0cr making this Cmifin¢of Exemption,you should - - - _ ---- -
become subject to Ne Worker's Compensation previsions of the I-mar Code,you must
.J Z forthwith comply with such provisions or Nis pormiuhall EC deemed mvoked.
Z O CONS RUC'DON LENDING AGENCY
[--� I hereby alarm that there is a Com union lending agemy rod the performance of
lYi
the,work for which this permit is issmd(Soo.Mr?,Civ.C.)
6] Lender's Name
=z Leder's Addrcu
U O 1 certify that 1 ban read this application and sum that the abort infum ition is
correct.I agree to comply with all city and county ordinances and sum laws relating in
V building construction.and hemby aothorim reprctinutins of this city to color upon dm
r W above-mcmiumdproperty farinspection whipases.
(We)igmt,m save,indemnify and keep hamless the City of Cupertim against
L)I,IZ babinCimanpu udgmc or me Costs and raining expenses this firnit. may in any wayoccur against said City
C.5 z in
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E R GU TIONS.
Sigarlou4:---(:a .
Iwl
-roofs
rc Applicanl✓ComveDam
HARDO
MLS DISCLOSURE Type of Roof
Will the applicant or future Wilding acuNem store or handle hazardous material
az defined by he Cuper ince Municipal Code,Chapter 9.12,and dm Health and Safety
Code, es riYa 25332(a)+ ` / All roofs shall be inspected prior to any roofing material being installed.
Yea ®Na
Will the apphemn.,.future buy emg occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contamivnts de0In d by the Bay Area Air Quality Management all new materials for inspection.
Disuip7 /
❑Yes fr9hpr„
1 have mad theh embusumamrials tc ormometunder Chepmr6.95oftheCalifor-
aia Heath&SafctyCode,Sect.25s05.25533 and 25534.1 understand thaitthe Wilding '
does not Currently ban a tenons,that it u my remOndbili,y w aadl'y the occupant of Ne
mquis nv which must bo CI me,m co.art Certificxm of Occupancy.
�J (Y Signature of Applicant Date a'
w or as o ag , Dam All roof coverings to be Class "B"or better