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04050166 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTORINFQRMATION *. BUILDING ADDRESS: SKELETAL KINETICS PERMIT NO 04050166 10201 BURR RD ER'S NAME: PERMfr ISUE DATE SKELETAL KINETICS „r0 ,JE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGELECT PLUMB MECH 0 t E e00 LICENSED CONTRACTOR'S DECLARATION Job Description i u� 1 hereby affirm that I am limnedm under provisions of Chapter 9(comencing with Section R(W)of Division 3 of the Business and Professions Code,and my license is „ infull form aadeffect. TI--UPGRADE Ej©ZPry PARTI-WALLS Q ` ;y p�M Lic.11 z License Clue pro Deam Cmil, FLOORING UPGRADE ARCHITECTS DECLARATION I understand my Plans shall he used az public records JUN 2 2004 3 o y Licensed Professional S OWNER-BUILDER DECLARATION f I herby affirm mat 1 am exempt from the Contractor's License Law for the r oo following uuoo.(Smuun 7(n1.5,Business and Professions Code:Any city or only BUILDING yS ff which reyui.a permit to emtsvum arm,,improve,demolish,nr repair any structure B Y V _Ieprior to its routim,also scqumet the applicant for such permit to file a signed summent that he islicensed pursuant to the Provisions of the Conlrumri Limnse Law(Chapter 9 Sq.Ft.Floor Area Valuation Commencing with Section 7")of Division 3 of the Business and Professions Code)or i that he is eumpt thertfrom and dm heti for the Jicgcd exemption.Any violation of $30000 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not mom Nan Few hundred dollar,(5500). 0 1,m owner of the pmpmy,m my employma with wages u der tilt compensation, will do the work and the svucure is not intended on offered tonal.(Sec.7W.Business 5 72 U 070 , and Professions Code:The Contractors Limese law docs not apply m an owner of Required Inspections propsny who buildsorimp rams thrown.and who does such workhimulf orthrough his awn employees,provided that such improvements are not intended oroRcred for sale.IL how<ver,the building or improvement is mid within one year of completion,the owner- builder will haw the burden of proving that he did not build or improve for purpose of sale.). 0 1,as owner of the progeny.am exclusively contracting wish limosed contractors to construct the project(Sec.7064,Business and Professions Code:)The Contractors Li- u taw does not apply to an owner of propeny who build,or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contxmota r(�Ines Law. ame.emp tomer Sryec B&PC for Nis mazon SV �X-esY K-l-cea Date ti�Z6-u W9RKER'S COMPENSATION DECLARATION W.hereby affirm under penalty of perjury one of Ne following 0 1 have and will maintain a CeruGcato of Conscnno self-insum for Worker'sCompen- xtien,u provided for by Section 3700 of Ne labor Code,for the ped orma«e of the .it for which this Permit is issued. 0 1 haw and will mzinuin Wmkcr's Compensauon Insurrce,as mounted by section 3700 of the labor Code,for the performance of Ne work for which this permit is issued. My Workers Compensation Insurance carom and Policy,number are: Cartier. Policy Ne.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu section mod not be completed link Permit is foron,hunmaddoliars(SIW) or less.) 1eerily that in the performance of shc work for which this permit is issued,I shall not employ any pcsseQj�ry manner sols, become4bject to the Workers Compensation Laws of California.Da - Applicant /iw NOTICE 0O PPLICANT.IL after making the Comfits¢of Eacmption,you should b«ome sat m to the Worker's Compensation pmvisions of she labor Cade,you most .J z fpMwi amply with such provisions or Nis Permit shall be deemed revoked. zCONSTRUCTION LENDING AGENCY Fr .N-, I hereby affirm that mere is a constroctinm lending agency,for thcp ornmounec of C' the work for which this permit is issued(Sm.3097,Civ.C.) Lender's Name , z Lender's Address U O 1 cot that 1 have rad this application and sum that thc show information is ' f" correct 1 agree to comply with all city and county ordinances and slam laws relating to DU building construction,and hereby authority representatives of this city to enter upon the r LU aloe-mentioned property for inspection purposes 0. (We)agree to saw,indemnify reit keep hardest the City of Cupcnirm against rn liabilities,judgments,costs and expcma which may in any way secom against said City U^ in APPLICANof me T of NTUNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date SOURC LaTIONS. _)� `�, v /�-" '_ Re-roofs tort AppiicanUContfactor Dam HAZARDOUS MATERIALS DISCLOS E Type of Roof Will the applicant or furore building occupnatmore ar handle hanrdeus material as defiSection ned by the CuMnino Municipal Code.Chapter 9.12,and the Health and Safety`'pY�zss3z(a)7n All roofs shall be inspected prior to any roofing material being installed. Will mea licam or future building Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove PP g p equipment or devices which emit hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. Disuics7 0Yes Nu I have read me hazard us materials requirements under Chapter 6.95ofdim Califor- nia Heal m&Safety Code Sections 25505,25533 and 25534.1 understand mat if lM Wilding d«s not et reedy have s tena that u n ely resporoihiloy t madly de«cupant of me requiu w hmus, norIn1.amm�ncenigcsof(xcaantsy Signature of Applicant Date 17 Owne atrmonndagent Dam All roof coverings to be Class"B"or better