03110106 L
ITY OF CUPERTINOBUILDING DIVISION PERMIT CONTRAC-TOR INFORMATIONLDING ADDRESS: PERMITNfb 3 110 10Fy
ER'S NAME: PERMIT MUE DATE
M LEE 11/20/2003
NE: SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION OO O
f Z C I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Des
h S
<b with 4IX0)of Division 3 of NC Business and Professions Code.and my license,is'
na in mummeand affect. ADD GARAGE 495 SQ. FT..
jt2? License Class Lic.0
to Dam Contractor 9 2004
ARCHITECTS DECLARATION SEP wB
f w U I and n my pl ns shall he used az public,vCnralt �f.
la�eenseIh eyaffir Lr �e� 'se BulL®
S OWNER-BUILDER DECLARATION
a S 1 hereby al'frm that I em exempt from Ne,Contractor's License Law fur,he,
p o following reason.(Section 7031.3,Business and Pmfcssions Codc:Any city or county
3$ which requires a Penni,to construct.alter,improve,demolish.m repair any structure $53054
_Za prior to its issuance,also requires the applicant for such Permit o file a signed statement
ggSp that he is licensed pursuant o[he Vo isinnsoftheContractor'aLicenxhw(Chapter9 Sq. Ft. Floor Area Valuation
ts- (commencing with Section 70W)of Division Sof the R usince,and Professions Code)or
is
that he is exempt memfrom and the hasis for the alleged exemption.Any viplatlnn of 11
Section 7031.5 by any applicant for a permit subjects the e applicant to a civil Penalty of @NO G
nore n five hundred dollars(SSW). Occupancy y Type
0,az owner of the property,or my cmploycn with wages as their sure compensation.
will do Ne work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License law docs act apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,one building or improvement is sold within one year orcomplction.the owner.
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
Conswet the Project(Sec.7014.Business and Pmfcssions Cot The Contractor's Li.
cense Law does not apply,o in owner of property who Wilds or improves thereon,and
who contracts for such projects with a eonuaaor(s)licensed pursuant to the Contractor's
License law.
❑I Am exempt under See. ,B&P C for this mason
r Data
WORKER'S COMPENSATION DECLARATION
I hereby fran under pcearly of perjury arc of tbe following dalaratire s:
I have and will maintain a Cer ificux of Curator to self-insure for WorkersComPen-
sation,At,provided for by Section 3700 or the Labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,As required by Section
37M of the tabor Code,for the performance of the work for which this Permit is issued.
My Workch Compensation Insurance artier and Policy number are:
Coricr, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one hundred dollars($1110)
or tai)
I unify that in,he,performance of the work for which,his permit is issued.1 shall not
employ any person in any manner sou to become subject o the Worker'Compewtion
LA ws of Califomia,pa�
APPiican,
NOTICE APPLICANT:1t.after making mix ligmaleof of Exemption d you should
been jece m the worker's Compensation provisions of the labor Code,,you must
0 fonhw, comply with aucM1 provisions or this fermi,shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
1 hereby Affirm that there is a construction lending agency for But performance of
tai the work for which this permit is issued(See.3TB7.Ci,C.)
LUQ lender's Name
=z tender's Address
rJ Q I ccnify that 1 have read Nis application end state,hal the shove information is
F-' Coea r 1 agree m comply with all city and county ordinances and sure raw's,crating to
U building construction.and hereby authmue reprexntaivus of this city to enter uponthe
how-mentioned nmpc to for expenses which may
'ewe liabilities, menbe,costs indemnify
and
dke marpolaany�City of Cupertino again,
tq 6 a yway accmc against mid Ciry
U 2 mcnnxq NT UNDERSTf the ANDS
of this KimWILL
^' APPLICANT UNDERSTANpS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RCE REGU_ LAT�NS. y
Signature 01 ApphcanUCo,nracmr —j am Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous maxtlar
az dc"SoCI by e yenhM Municipal Code.Chapter 9.13and the Hcalth and Safety
.SCNon th25533Cu(x)7 ,`'
❑Yea 09 Nm All roofs shall be inspected prior to any roofing material being installed.
Will mea licam or furore building mea ,axe If a roof is installed without first obtainingan inspection,I agree to remove
PP B pan quipment or dcviaa which p g
Z'
ha ardnus air contaminants as defined by the Bay AKA Air Quality Management all new materials for inspection.
Dinric4
❑Yes �Nu
I have read the havardnus araxrials oupincmems under Chapter 695 of me Califta-
ria Health&Safety Cock,Socdos¢25515.35533 And 25534,r tookorund Nat if the la ilding
dues not currently haw a xnam.that It u my fesponsiblllty to no ily the<up rat of the -
requirementswhichmusthc me,prior it)issuance of a Ccrtificax (Occupancy. Signature Of Applicant Date
owne[Orra`, ochicdagen, `r DA,e All roof coverings to be Class "B"or better