04030056 CITY OF CUPERTINO '-`9•- 'r^''� s�
nmLmNc DIVISION PERMIT a1CONTRACTOO RINFORMATION w
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BU ILDING A DD R ESS CW wBUILDERS PERMIT N004030056
OWNER'$NAME: PERMITISSUEDATE
SHEW FRANK
NE: SANITARY NO. CONTROL NO.
(408) 378-4323
ARCHITECI'yENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Opp LICENSED CONTRACTORSDECA ON
1 homy affirm that I am d underprovisions of Chapter 9(commencing Job Description
.zw with Section)Olgq of Division 3 of the Business and Pol4sions Code.and my license is
ren yy[[��de« G NEW BLOCK WALLS JJ\\
>eeZ in .11 los Q Lich J/
Dam used
CONTRACTOR: CW BUILDERS
Ft�-ABCIIITECTS DEC A A /
w d 1 un�Jprstxnd plana shall he uxcJ as puJi
t o G Lic Pndcasinnal C
OWNER-BUILDER DECLARATION
M1 hereby affirm that 1 am exempt from the Contractor's License Law for the
0 c following mann.(Section 7031.5,Business and Professions Cndc:Any city it county
K m which requires a permit to construct,alter,impm na,demolish,or repair any stuctow
Lzi prior in its issuance.also requires the applicant forsuch Permit to file a signed statement
a
that he is licensed pursuant n the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
yF� (commencing with Section 70(1 (it Division 3 of the B usinas and Professions Code)rr
i that he is exempt thcmfront and the basis for the alleged exemption.Any violation of $5000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars(g500). P Y YP
❑ I,as owner Of the Property.or my employees with wages as their sole compensation,
will do the work,and the structure is not intended Lir Offered for sale(Sec.704,1.Business
and Pmfeasions Code:The Contactor:License Law dna not apply to an owner or Required Inspections
property who builds or improves maroon,and who does such work himself or mmegh his
wn cmployces,provided that such improvements are not intended or offered for sale.IL
bowevcr.the building or improvement is sold within one year of completion,the owner-
builder will have the burden e(proving that he did not build or improve(or purpose of
sale.).
❑1,as owner of the properly,am exclusively contracting with licensed contractors to
construct the pmject(Sec.7044,Business and Professions Cole:)The Contractor's Li
ecom Law does not apply to an owner of property who Wilds or improves Ihemon,and
who contacts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑1 on exempt on&,Sec. .B&P C for this mason
wner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty Of perjury one of the following fluctuations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by section 37M of the Labor Code,for me performance or the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
37Wof the Labor Cone.for the performance of the work for which Nis permit is issued.
6MM WWmke'a pensatlon Insunnc our and I`Noy nu bei I
CtE IFICATEOFE EMPr10N WORKERS' 003
V COMPENSATION INSURANCE
(Thu section need not W completed if the permit is for one hundred dollars($IS))
,r less.)
I certify that in the performance of the work for which this permit is issued.1 shall not
employ any Person in any manner an into become subject to the Workcri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicar of Exemption,you should
become subject to the Worker's Compcwtion provisions of the Labor Code,you must
�Z. (onnwbh Comply with such provisions or this permit shall W deemed mvoked.
z'O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a comstmetion lending agency for the Performance of
{.Y. the work for whieM1 this p.it is issued(Sec.3197.Civ.C.) ,
Il.1 Q Lender's Name
2 Lender's Address
V 0 1 certify Nat 1 have read this application and stem that the about information relating is
0 F^ cording 1 ogre ct comply with all city and county ntativ s Of and Cott laws r lacing to
pU anowngconswmion.and horny amborimrpresematives of this City mcmer upon the
4 ahnvc-mentioned property foremnifan purposes.
(Wt)agree to cast,indemnify y and keep yinharmless the y ac of Cupertino against
JD,IZ in
equnce of the
uang expenses mit. may in any way acerve against said City
V z APPLmqucncc of the Framing of this permit.
^ APPLICA UN STA s AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE r U AT
ssisn m ornpplie "`t7rr'�'—�^� r Dana Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Lir future building occupant Bore or handle havallous material
defined by the Cu
pcn
0inn Municipal Cors.Chapter 9.12,and the Health and Safety
ale. Ycnzss3z(a)^ o All roofs shall be inspected prior to any roofing material being installed.
Will the a Bcant orbuildin Dern ant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil
District,
nus air contaminants a rsfincJ by the Bay Arca Air Quality Management all new materials for inspection.
Diatria7 _
byes ' 12—(N\
1 have read the hararthms materials requirements under Chapter 6.95 of the Califo>
ria Health&SaretyC Secomm 25515.25533 and 25534.1 unsmad that if the building
does not curtcnuy at a is my responsibility m my clic n'cupant fir me
ragairemenmwhia fit rloi �tniBta a, Signature of Applicant Date
Owner Lir authonrcJ agtm `�`�A Dam r All roof coverings to be Class "B" or better