03010114 CITY OF CUPERTINO y. `-„� m,«a::• �'
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PERMIT CONTRACTIOR INFORMATION:
BUILDING ADDRESS: JM BASALDUA CONST PERMIT NO.
10354 BYRNE AVE n'AniQ114
W ER'S NAME: 15 HARTNELL RD APPLICATION SUB DATE
•CIM LIMON 01/22/2003
ONE: (831) 754-4788 SANITARY NO, CONTROL NO.
ARCHGDCfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONnsed 4R'S DECLARATION
s�¢P 1 hereby affirm that I em licensed ansa§§§§§§provisions of CM1apler 9(commencing Job Description
< win Section (Nk)of Division3nf the
BusinekRhnd Professions Gd and mylicense is
ZO'%< wfullfonead cl ✓•• SEWER
jZ License Clms e Lic N
Dy^t,p Dam - -O Cunt rtY .M- •noJd Y
<yq"f ARCUTECTSD ARATION y
fie''CC 22 3 I fare unJ my plans shall he uscJ as public rccoNs
m3Q Licensed Pndcmiunal
5
OWNER-BUILDER mDECLARATION �U�a
u6"j 0 I hereby.Beth that 11. exempt from the Contractor's License Law for The y �a
o o which re rensreasa ertenSectit 71131.5, t,alter,
and Professions h,or Any city or rummy
ae which requires issuance.permit a construct,alma impnwq demolish,or repair any structure
Zj, thatheor its esePummCct0 the The inion ofthe Contennt lorsuch rmiuofiensele Law(Chnad statement V4
ts< thatnein licensed PSection come of Division 3 ofthe Boa mraucenmlyons Code)
Sq. Ft.Floor Area $`2��IQJItIOn
��° (commencing with Section 7lwl)nrpivisinn3mme eaamnm ana Proreaainna rnee)m
y
that he is exempt dominion and The basis for me alleged exemption.Any violation of
section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of e Occupancy Type
not more man five hundred dollars(53110).
❑I,m owner of the property,or my employees with wages u their sole compensation,
will do the work.and the structure is not intended or offered for sets(Sec.7044.Business
and Professions Cock:The Commodes License Law does not apply to an owner of 202 - IJNDERFe L UlYlti Y LV G
property who builds or improves thereon,and who does such work himselforthrough his
own employees,provided that such improvements me not intended metered Intrinsic.If. 301 - ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the owner-
builder will have the human of proving that W did not Wild or improve for puryose of 302 — TUB & OR SHOWER
sale.). 502 - FINAL PLUMBING ENERGY
❑1,as owner of fee property,am exclusively contracting wife licensed contractors to 506 - GAS TEST
construct Ne project(Sec.704q Business and Professions Code:)The Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves themes,and 507 - FINAL PLUMBING
who contracts for such projects with a commucto
r(s)licensed pursuant m the Cralose o's
License Law.
❑ erupt under Sec. B I&P C for this Yemen
WORKER'S COMPENSATION DEC ON
I hereby affirm under penalty of perjury one of the ng declarations:
❑1 have and will maintain aCerliOcamof Consenttosel-in rWerker'sCompen-
sation,u provided for by Section 37M of 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 labor Code.for the Performance of Ne week for which this permit is imucd.
My Worker's Compensation Insures a carrier end Policy number arc:
Ca '1: Policy No.: �i`"QZ9 Ul -OZ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbissection need not Weempleted if the Permit is torose hundred dollars($100)
or Iem.)
1 codify that in the performance of the work for which this Permit is issued.I shall not
employ any Person in any manner so u m become Subject 10 the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making his Ccni Here of Exemption,you should
become subject to The Worker Compensation provisions of the LWr Code,you must
OO forthwith comply with such provisions or this perm it shallW deemed revoked.
CONSTRUCTION LENDING AGENCY
[-t I hereby affirm that there is a construction lending agency for the performance of
r(y > the work for which this permlT is ironed(Sec.3097,civ.C.)
aQ Lender's No
7. Lender's Address
U Q 1 certify that I have read this application and stem that The above information is
ly Pcorrect,l agree to comply with all city and county ordinances and state laws relating to
DU building Construction.end hereby coheres repoescraillcs of this city to enter open The
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hmmlcss the City of Cupertino against
,.y W liabilities,judgments,costs and expenses which may in any way accrue against said City t
U 4 in consequence of The granting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGULATIONS.
22 > Re-roofs
P
c of APPmanUContramon Dam
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
t
Will theapplicamor future (ding occupant store or handle havardous material
m defined by the Cupertino Mumpal Cede,Chapter 9.12,and The Health and Safety
Code,Scales 25532(a)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ofV
ing occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit haaallous airconmerined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
1 have mad me havardousnnamenals requirements under Chapmrti.95 of the Califor-
nia Health dtSafetyCede,Seetions25505,25533 and 25534.1 understand Nut lithe building
does not comedy have a tensa,mat it is my responsibility m nodfy the meup rm of Ne
qui men which Masi WMCI Prior mimuunceufitCerdficamofOccupancy. Signature of Applicant Date
Yj� z_0 All roof coverings to be Class "B"or better
Ounicisfir authorized agent - Dam