04030192 CPCY OF CUPERTINO •''
BUILDING DIVISION RMATIONei
BUILDING ADDRESS: PERMIT NO.
04030192
'ER'S NAME: PERMIT LSUE DATE
J\
O10 qft
NE:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
t� E [�
+�+oo LICENSED CONTRACTOR'S DECLARATION Job Description
w p 1 hereby affirm Nat I am licensed under previsions of Chapter 9(commencing P
2w with Senion7(n))of Division]nfthe Businessand Professions Cude.and mylicensa is
mfull nmmaeae`f ADD 736 SQ. FT. /GARAGE 427 SQ. FT.
j ln
i LLicenseClasss Lic.X
L�'w Dam Contractor
_
ARCHITECTS DECLARATION
09 j
I undersand my plans shall he used as public meords
JnU
y
Licensed Professional
iyg OWNER-BUILDER DECLARATION
Conti ON
1 hmaxo .(Sero Nall 1. exempt from me Contractor's Cade:License taw foe tht
f o o followwhiching o:ama(Sccuun'constr Business and ve.de i oli h,oAny cin or county
K m which requires a issuance.also tit construct,alter,improve.h Permit to
mean any sw<mre 61
u�'^ that heor itsseedposialart WiresIN the applicant for sucContractors
mietnule am ned statement
aw(Chapter9
that me cing wit purwam mthc or Dishnuar theeM Busier'Wammlaw(Chapmr9 Sq. Ft. Floor Area Va auon
that he is exempt Section)0 and
the
Division]of EM alleged
Business and Proresson.Any
CMe)of
that he o exempt mcmfrom and dm buts for the alicged exemption.Any viohtion of
Section 70]1.5 by any applicant far a petmi,subjects the applicanuo a civil penally of 3 5,TN51b(fi0er0 0 Occupancy Type
not more Nan five hundred dollars(5500). ,
I,u Owner of the pmpcny,or my employees with wages as;their sale compensation,
will do the work and the swctum is Tat intended or offered for sale(See.7044,Business
and Pmresdom Code:The Contractors License,law does Out apply a an owner of Required Inspections
progeny who buildsor improves Ommon,end who dcm..bwarkhimselfonhmughhis C4own /
mployecs,ping or improvuch ement
is
wit in not ear ofdmoRemd the ow. r-
however,me building or den of proem tx sold within one year of completion,the ower-
builder will has One burden of proving that he did not build or improve rte purpose of
p(L as owner of de progeny,am exclusively convening wife licensed contractors to �l
construct the project(Sec.7044,Business and Professions Code:)The Conuaemri Li
ccue law dors not apply in an owner of pmpcny who builds or Improves themon,and
who contracts for such projects with a eomnemr(s)licensed pursuam to me Conuacmts
License Law.
I sure 7,1 under Scc. .B&P C for this reason
am °
CWORKER'SCOMPENSATIONDECLARAiPICIN
1 hereby affirm under penalty of perjury am of the fallowing declarations: /
1 have and will maintain a Cmalma a of Cement.self-insure fur Worker's Carrico.
seniors,uro
provided for by Section 37Mof mbo
e lar Code,for the pcdarman¢of the
work for which this permit is issued.
F1 I have and will maintain Workers Compensation Insurance,as required by$acllon
37W of the labor Code,for the performance of the work for which this permit is issued.
My Warker's Compensmion Insurance carrier and Pali,number am:
Cartier. Polity NO.:
CERTIFICAM OF EXEMPTIONFROM WORK ERS'
COMPENSATION INSURANCE
(This union need not MeamPlemU if the Permit is rot one hundred dollars(Slap 3// ICQZ(//l J\
or lcssJ
1 certify that in the performance of the work for which this permit is issued.I.Nall not
employ any person in any manner so as to become subject to the Workers Compensation '
Laws or California.Dam
Applicant _
NOTICE TO APPLICANT:If,after making Nu Certificate of Fscmption,you should
become subject to the Worker's Campemookin provisions of me Labra CMM.you must
.J O farmwife comply with such provisions or this Permit shall he deemed mvakcd.
Z " CONSTRUCTION LENDING AGENCY
[-. I hereby affirm that roan its construction lending agency for the Performance of
C 5: me work far which this permit is issued(Sec.30SI.Civ.C.)
SQ Lendces Name
Z 1<ndces Address
C.1 Q 1 certify that I have read this application and sum that the above information is
Iy Ftorten.1 agree to comply with all city and county on inan¢s and sum laws misting in
0 building convection,and hemby ashorim iprescraiives Of this City to cnmr upon the
W some monitored property for inspection Proposes
(•" y (We)agroe m save,indemnify and keep harmless the City o(Cupcnino against
N fiabilities.judgmcnts,costs and expenses which may in any way accost against said City /
UZ in consequence of the granting of this Permit. t/
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
c o ApplmanV u�gt 7u � Dam 41
HAZAIIDOUS MATERIALS DISCLOSU Type of Roof
Will the applicant ser future building occupam amro os handle havallons material
as defined by the Cu'espertino Municipal Code.Chapter 9.12.and de Health and Safety
e,Snout All roofs shall be inspected prior to any roofing material being installed.
bout ON.
Will the applicant or future building Occupant use cquipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Disvint?
❑Yes �No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHulth&Safety Cw .Secu=25505,25531and25534.Iun&nwdW iftlte Wilding
data Out currently have a tenant that itis my tesporteibility b notify Ne omupant of the
mquimmtmiw hmuatxmctpdorionsuanceonGertireatcorottaPanty. Signature of Applicant Date
""a^" All roof coverings to be Class "B" or better v
Own ullarizeda c Das