03100173 CITY OF CUPERTINO ,,,k
BUILDING
BUILDING DIVISION PERMIT CONTACTOR,.INFORMATION:4,'
BUILDING ADDRESS: MERCER CUSTOM CONSTRUCTION PERMITNO03100173
i
'R'S NAME: 619 HAWTHORNE AVE PERMIT ISSUE DATE
SOUR DAVID P JR AND DEBRA M ET 10/23/2003
PHONE: (408) 374-8782 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 sm licensed under provisions of Chapter 9(commencing Job Description
�•t<ul wire Section 7000)of Division Star the Business and Professions Code.and my license is
mranferceanderfea. REVISION--IN HOUSE USE ONLY
s Z License Class Lk.9
Data Cantrmnur NO NEW PERMIT ISSUED, ORIG. #03080030
'y ARCHITECT'S DECLARATION
I�q1 understand an,plane shell be used as public records
JWO
'0 Licensed Professional
e OWNER-BUILDER DECLARATION Og\
E 1 hereby.from that I am exempt from the Contractor's License Law for the V
.00 following moon.(!mdun 703 1.5.Business and Pmressions Code:Any city or county \F�
<2� which requtroa a Permit In Construct.alter,improve,demolish,or repair my structure V
poor to its issuance.also requires the applicant for such pimaro file a signed statement
< that he is licensed pursuant m me provisions of the Centimeter's Ucense law(Chapter9 Sq.F[. Floor Area Valua[io�107
e�D (commencing with Section 70W)of Division 3 or use Business and Professions Cook)of
$ Net he b exempt therefrom and me bub for me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Occupancy Type
not mom than five hundred doll..(5500).
❑ 1.as owner of the property,or my croploy ear with wages as their sale compensation,
will do the work,and the structure is not intended in offered for sale(Sm.IDN,Business Required Inspections
and Prefessiory Code:The Contractor'sLiave Law docs net apply to an owner of e q P
property who buil G or ,im pravea thereon,and who does such weak himseIf or tluough his
own employers,provided thatsuch improwmenu are not amended or offered for ule.If.
however,the building or improvement is sold within ane year of completion,the owner.
builder will have the burden of proving that W did Wt Wild or improve far purpose of
sale,),
1091
Q ss owner of the property,am exclusively contracting with licensed contractors to
�nmuct the project(Sec.70".Business and Professions Cade:)The Comracmr3 Li.
Genu Law not split in owner or property who Wilds or improves thereon,and
whocanvae a with a canvamea(s)licensed puni.at he the Canvaaor.
Lk:enee Lew
Q lam ca to B&WC forthismoon
er Da (/- y� ,
W ENSATION D RAT i`1 � -
I by affirm under penalty of perjury an of the following declarations:
❑I hew.nd will maintain a Certificate of Cement to selfdnsure for Worker's Compere- .
.tion.as provided for by Section 3700 of the labor Code,for the performance of the
work far which this Permit is issued.
1 have end will maintain Workers Compensation Imus nce.as matured by Section
3700 of the IaWr Code,for the performance of the work far which mu Permit is issued.
My Workers Compensation lots.ce carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sbe inn need noh,compietad If the permit is forma hundreddollan(5101))
or lcs )
1 certify that in the performance of be,work for which this permit is issued.l shall not
employ any person in any mennerm as in become subject to the Warkeri Corapensadon
Laws of Califamia.Data
Applicant
NOTICE TO APPLICANT:If.$fact making this Cenificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Iabor CMC,you most
� Z forthwith comply with such provisions or this Permit shell W deemed revoked.
OCONSTRUCTION LENDING AGENCY
1 hereby affirm that mere its construction lending agency for the perfurmanco or
L' the walk fur which thb permit Is issued(Sec.309'1.Civ.C.)
LQ Leaders Name
z l<ndue,Address 1
a O 1 Canary that 1 haw reed rob application and suite that the allow information is
(-' correct.I egme in comply with all city and County oNlNnwa end utak laws ml.liag to
C.) building construction,and hereby authorim rePmaentniWS or this city to enter upon the
rTlohm mcmiuncdp for inspection purlwse3.
(WC)egme m ve,Indemnify and kap terminal the City car Cupertino Against
y Ilabili'a,jud mums send expenses which may in anyway Beene against sold City
;J z in co -.0
c of e r ting of this permit
Z APP CA "Ang
ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO E G
Re-roofs
re afAppl UCont ct D ta e of Roof
HAZARDOUS MATERIALS DISCLOSURE Typ
Will Ne applicant car fuwre building accts. tlorc or handl,haesrAem material
dcRoad by the Cupertino Municipal,Code.Chapter 9.11,and the Health and Safely
Section 15532.)7 All roofs shall be inspected prior to any roofing material being installed,
p Yrs me
1I,, Will the applicant or(stairs Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Grill 114MIC us air conuminens as defined by 1W Bay Area Air Quality Management all new materials for inspection.
Manic"
❑ c
I have ad u r smamdelsmquimmen3under Cheptar6.95ofine Cali(o,
nae Hcelth& ty, ode. C M15505,1.5533 and 15531.1 understand that irtho Wilding
docs note n haw .Ihbmy rapomihilitymnntil'y tiw.'caput of the
require ta into oroissanea can n ora Pan,y.0 Signature of Applicant Date
owners a risJe t w Dan, All roof coverings to be Class "B" or better