04120027 CITY OF CUPERTINO
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BUILDING DIVISION PERMITGONTR ,
- -
BUIIDINGADDRESS: LEAHY CONSTRUCTION FERMTTNO04120027
10180 N BLANEY AV
OWNER'S NAME: PER ISSUE DATE
MICHAEL GARVALE 1253 MARKET ST. 2004
SANITARY NO. CONTROL NO.
(408) 605-4805
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
TRO O
z I berchy or.Nal I am licensed under pAvisimu of Chapter 9(cu maKing Job Description _. .. .
<<s with Sectio)0t10)of Division 3 of the Bud✓!Iailj Pmfessioru Code,eM licenuis
^_„ notices. L REVISE--IN HOUSE USE ONLY
='z Idwn Tic.g
=F� D RCHITETSD rARA (111 NO NEW PERMIT ISSUED/ ORIG. #04070169 - -
1 and send y ons andl hn use {mhbi c
Or
=yU i
GG Limo fcuionel w
3 WNER-BUIL ERDECLARAT N `-
.� y I hes rem Nat I am exempt from Nc Con oars License Law for the
0 o fellnwing mason.(Seed.7(131.5,Business and Prufead m Code:Any city or county
which requires a permit m construct,alter,improve.do clism car.pair any structs.
FZj prior an its issuance.also requires thcapplicent for such permit to fit...gnmi mmmcnt _
s that be is licensed pursuant lethepmvisiomofthe Common's U..Law(Chapter 9 Sq.Ft. Floor Area $p—
�H (commencing with 5¢tion 7000)o(DivisionJ.f the Business and Professinv Cnde)m
y - load be u exempt therefrom and the bus for the alleged eumpuon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
mtheumber N - Occupancy -
t m.. .five hundred dmlara(M). 31631024 . 00 APN NN P y Type
0 1,an owner of de property,ce my employees with wages as their sole compensation,
will do the work,and the swmum is not intended or offend forsale(Sec.7044,Burins
and Prefcaei°m Code:Tho Consumers License Law does not apply to an owner of Required Inspections
progeny who Wilds or i m proves thereon,and who docs s uch work himself or through his
ownemploycm,provided that such improvements arc not intended oroRered forsake If,
however.Ne building or improvement is sold within one year of mmpleuon,Ne owner.
builder will have the Baden of proving that he did not build or improve for pugme of -
sale.).
0 I.as owner of the propcny.am exclusively conuxti.g with licensed contractors to
construct Ne pmjm(Sec.7044,Business and Prefesdom Cade:)The Conuacmr's Li.
cave law docs not apply to an comer of property who builds or improves thereon,and
who mouacts for such projects with a contractor(s)licensed pursuant so the Conuacmrs
x Law.un exempt under See ,Bk PCfar this remon
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby at<rm under penalty of perjury..of the following dmisnuov:
0 1 have and will maintain aCertificare efCovent to wif-insure fer Worker's Compen.
satin.,m provided for by Seeuen 37W of the Ichor Code,for theperifit. ce of the
work for which this permit is issued.
0 I have and will maintain Workers Compensation Imuran.,as required by Section -
3700of the labor Code,for Ne Pm1mmance of the wort for which Ns permit is issued.
My Workers Compemmon Imunnce carrier and Policy number a.:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or less.) eccompleted(Tris section reed not he if the permit is for one hundred dollars IS 100)
1 certify that in the perfe the work for which this permit is issued,l shell mm
employ any person in neesom in become subject to de Workers C°mpoessuon
I
"'
California.Dau
t
TO APPLICANT:If,after making ths Certificate of Exemption,you should
Object m the Worker's Compensation previsions of tM labor Cres.you must
z comply with such provisions to this permit shall M deemed mokcd,
' O CONSIRUCION LENDING AGENCY
(ti I hereby affirm don me.isoem.suction lmdingagency for the pmfurmenc..f
1' the work for which this permit is issued(Sec.31197,Civ,C.)
aA Lenders Name
z lenders Address
U Q 1 certify Nat 1 have read this applicado"and state that 01111 ofotmetiun is
Fmrrcm.1 agree to comply with all city and county edim.ces and sate laws muting to
C.7 building conatOd h
clum,anerebyautbarive. us
prenmiM.fthis citftymcmcr upon
shove-mensiond progeny for impeeden pnrposea �/—_!/�/a/
H y ( agree to save,indcmmfy and Fecp lurmless the City of Cupcnino agaimt
h liebiliY .J dg hncaatsi upvmmw Rh req in any way accmc egaimtseid City
V z in co qts c fthc Brandgqg of this per is
APP ICA NDERSTANDS AND VILL COMPLY WITH ALL ION OI Issued by: • - Date
SO RCE U ATION // ✓/'✓
Si nowicanuCo tsaclor Re'roofs
HAZARDOUS MATE ALS DISCLOSURE am Type of Roof
tbeapplirant orfuture building occupants..or Mndle v our mamdaf
as defmcd by drc Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
y
Code. 0 eau53ua)e 4p All roofs shall be inspected prior to any roofing material being installed.
❑Yes YINu -
Win the applicant or fu re building occupant me cr ipmens or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haraNnut air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
0Yes No
I . e amWs rials. I omurm Ch.mc,6.95m`mc Califon
nice Hcal Safer ,Sectio 505.2533and25334.1 urtmer ddm if Building
dour no vecn on a tenank at its y responsibility m notify the cu t of
aqui us(be pngs,tars u eC'rub, sec pO
� Signature of Applicant Date
rm r honred agent D,p All roof coverings to be Class "B"or better