04070065 CITY OF CUPER'11NO
BUILDING DIVISION PERMIT ACONTRACTORINFORMATION �-
❑UILDING ADDRESS: IJ TION PERMIT K94<]7 �Tj
0981 BARRANCA DR
OWNER'S NAME: PERMIT ISSUE DATE
CECILIA MAROSI 1554 47TH AVE 10/15/2004
)NE: SANITARY NO. CONTROL NO.
(415) 566-5502
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MUCH
uoo LICENSED CON ,ACTOR'S DECLARATION L� O O
F❑ 1 hereby affirm that 1 am licensed uMcr provisions rf Chapter 9(commencing Job Description
?W with Section MX8 ofDivision 3 of the Business and Professi.m Code,and my license is
m sen force and edea. ADD 222 SQ. FT. (BEDRM) /REMODEL BATHRM
nLicense Class Lic.0
Z F a Dmc Cuntmcut,
4 Wj ARCHITECTS DECLARATION
K
3ya 1 understand my plans shall he used as public records
U
Soy Licensed rn,resain.al
i a OW NERBUILDER DECLARATION
+�<S I hereby affirm that I am exempt from the Contractor's License Law or the
p 0 following Mason,(Section 7031,5,Business and Professions Cade:Any city or county
K m ff which requires a permit.)construct,aper,improve,demolish,or repair any.structure $35000
F_R prior to its issuance,also requires the applicant for such permit to rile a around statement
Z= that that he is licensed pursuant to the provisions of the Contra:tor'sLicense aw(Chapter 9 Sq. Ft. Floor Area Valuation
Ch (commencing with Section T(XXI)of Division 3 of the Business and Professions Code)or
to. 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&civil penally of 2 2 OR b Occupancy Type
not msec than five hundred dollars 1$500).
❑1,as owner of the property.Or my employees with wages ss their sole compensation,
will do tic wank,and Ne structure is not intended or offered for sale(Sec.)Ola,Business
Ford Professions Code:The Contractors License Law does not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himself or through his
n employees,provided that such improvements are not intended or Offered for sale.If. lqp
however.one building or improvement is sold within one year of completion.be owner. �p�\�1!@j1�
builder will have the burden of proving Nat he did not Wild or improve for purpose Of y `Yl
salt.).
Lsto
1 owner Of the property.am exclusively contracting wit licensedcontnnorto 1OU5
co oust the project(So .70an,Business and Professions Code:)TO,Contractor's Li AYK y,z
erase taw does not apply to an owner of property who but Ids or improves Wromm.and
who contracts for such projects with a comractons)licensed pursuant to the Contractors r�
License Law. BUILD�f
❑l arp c Zap under— ,am PCC for t'S&sun I D
�� Omer 1LI� {I
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury One of the firfl` x�gR declarations:
Anand will mainudraCenificacaf Consent loxlf-insun:forWorker'sCompcn-
sation,as provided for by Section 37W of the Labor Code,for the perfmmance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 Of tic Labor Code,,for the performance Of the work for which this Permit is issued.
My Worker's Compensation Insurance,carrier and Policy number am:
Carver. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M rontplmed iOie permit is formic huMmd dollma($10(8
Icsa)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any Person in any manner.so as w become subject to the WorkersCompensation
Laws of California.Date
Arrive..,
NOTICE TO APPLICANT:if,afirr making this Cenifcatc of Exemption,you should
became subject to the Worker's COMPOGGGImr provisions Of the Labor Cak,you must
J z forthwith comply with such provisions or this Permit hall tic deemed revoked.
zCONSTRUCTION LENDING AGENCY
f" l hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Site.3097,Civ.C.)
aQ Lender's Name
=z Lender Address
J Q 1 certify that L have read this.,risme.and sure that the abort infmmmimn is -
Vronecl.1agree to romply with all city and county oNinanees and state laws relating to
buildingcon.wnio o!hereby mohmnm representatives of out city to enter upon the
&have-mentionedptoperly,b for expensestrucliti.Purposes.
H y (We,)agree to an,indemnify and keep harmless the City of Cupertino agai Fist
z inemnestionce of the
expenses Pewitch may in any way accmc against said City
V z m ennxyucnce of the gaming of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EGUL ONS
�Ogiatone of wppltcanUm
Cmnc Did. Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hararJuus material
u defined by the Cupmirmnicipal Code.Chapter 9.12,and the Health and Safety
Calc.S0 Yet 25532(a)? Hm All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
sit haramnus air contaminants in defined by the Bay Arca Air Quality Management all new materials for inspection.
&trim
❑Yes NO
1 have real the haraNnus materials requirements under Chapter 6.95 of the Califon
iia Health A Safny Cade,Secions 255115.25571 and 25.530.1 unJersmnJ that If Ne,building
rices not c- sty ha a tenant,that it vs my responsibility to notify tie Occupant of the
req cots w h at be mel rononn issuance 0(a Certificate of Occupancy.
oc� a 0 4 ) Signature of Applicant Date
Owner or authunled agent D,tp All roof coverings to be Class T"or better C�