05040110 CITY OF CUPERTINO `��' `"� xi, "'
BUILDING DIVISION PERMIT CONTRACgTnR INFO$MA.TION ;;
JLIER'S
ING ADDRESS:: N g /— WALDRON CONSTRUCTION COMP MITNODS040110
NAME: PERMrf ISSUE DATE
PROMETHEUS
E:
SANITARY NO. C NTROL NO.
ARCHITECI]ENGINEER: BUILDING PERMIT INFO
BLDG EIEC( LUMB PMECH
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uOo LICENSED CONTRACTOR'S DECLARATION lb Description
wCq I Mmby.affirm thoP
at I am licensed under provisions of Chapter 9(commencing
Zry with Section]IAM))uf DivisionJof NC Busine and Professions Code.end myliccnse is
in Tata force and
err`ci Lk.N 5032 f�
INTER. REMODEL (KIT/BATH)
,Fn
A
Date S DECLARATION
YE ARCHITECTS DECLARATIOON
yK I understand my plans shall Mused as public records
JyU y
o H Licensed Pmfcsamisid. yyCr/�-
S OWNER-BUILDER DECLARATION 6 /
Ee Z I hereby affirm that 1 am1. exempt from the Cessions c :Any c Lew for Ibe `
p 0 following mason.(Section](131.5.Business and Professions Code:Any city or county
E:m which ruts issuance.permit re corewd,altoe improve,demolish,nr repair any struaum
primmits ensedportio ,to the theapplicantfor Inch ContrarmiuOfile aicense ned aw(Chmmcm
QFti- (co menccenscd pSectam mtbc of Divions rat the Commaor'and Proelaw(C ode)or Sq.Ft. Floor Area Valu hon
C (commencing with Scaien]IX10)Of DivisionJnf NC Business and Professinnx Code)or
to
that he u 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 a civil penalty of 310231*41l16et00 Occupancy Type
not more than live hundred dollars(ML
❑1.umnerorthepmpeny,mmyemploycuwishwaguutheirmlecompemlion,
will do the work,and the swan¢is not intended or offered forage(Sec.1040,Business
ane Pmfessionx Code:The Comrectors License Law dos not apply to an Owner of Required Inspections
progeny who builds or improvuthemon,andwho doessuch work himselforthrough his
own employees,provided Notsueb improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owncr-
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
❑h as owner of the property,am exclusively contracting with licensed contractors to
construct the pmjca(Sec.7044,Business and Profusions Code:)The Conttacmr's Li-
ase,law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with aconhamr(s)licensed pursuant in the Conuacto's
Cie.I.
E]I am exemptunder Sec. ,B&PCforthisremon
Date
WORKER'S COMPENSATION DECLARATION
r thereby affirm underpenalty ofperjury one ofthe following decimations:and will maintain a Ceri fleate ofCOn1C111 to self-insum for Workers Compere
provided for by Section 3]00 of the Labor Code,for Ne performance of the
work u for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Stetion
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker Compensation Insurance carrier and Policy number art:
Cmrier. ti"tO 1�< Policy No.: 61VA OL15i 1
CERTIFICATE OF EKEM WTON FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not M completed if the permit is form¢hundred dollars($1(X6
or Itis.)
1 certify,that in the unf newmen of the work for which this permit is issued.l shall am
employ any person in any manner In as to become wbjecu0 Ne Workers'Compensation
Laws of California.Date
Apphcam
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
.JZ forthwith comply wish such provisions Or this permit shall be deemed invoked.
zO CONSTRUCTION LENDING AGENCY
P: 1 hereby affirm that there is a construction lending agency for the performance of
fx> the work for which this permit is issued(Sec.3097,Civ.C.)
WQ Lender's Name
04 z Lsndcr's Addmm
V O 1 certify tat I have read this application and state that the above inforfamun is
U.F correct.I agree to comply wit all city and county oNinances and sum laws relating m
O V building construction,and hereby authorie representatives of this city to enter upon the
r above-mcnaoned pmpeny for inspection purposes.
H D.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
fq liabilities,judgments,costs and expenses which may in any way accrue against said City
U in consequence of the grand ng of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
—t"!2cEGU
x� LATIONS. n
-� ft - rX 1011-119-5 Re-roofs
Signature of Applicant/Contractor ' Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant Smit or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
c.Section 255320)? All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
Will she applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haxartlnus air contaminants az definctl by tc Bay Area Air Quality Management all new materials for inspctiop� n.
❑Yes rNu
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cal'
nia Health&SafetyCOM,Salimu25505.25533and25534.lundersland tat if the riding �I` I _
dors not cumendy haw a temna tai it u my rcspmnsihility to nodly the Occupant of t
ts wMeh mast Mm tp. on.smenccofa Cerllficate Of Oceuparty' Signature of Applicant Date
��� -1-185 All roof coverings to be Class "B"or better
Owner authorized agent Date