03020095 CITY OF CUPERTINO " ,gX
BUILDING DIVISION PER 4RC ' NU1tMrCT,O
BUILDING ADDRESS: JM BASALDUA CONST PERMIT NO.
10354 BYRNE AVE
RS NAME: 15- HARTNELL RD PERMIT L%UE DATE
TIM LIMON 02/24/2003
NE: (831) 754-4788 - SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
�oo LICENSED CONTRACTORS DECLARATION Job Descrl tion
b 1 hereby storm that I am Ilmmed under provisions of Chapter 9(commcnchnt p
with Section 7000)or Division 3 of the Business and professions Code,and my license is
Lt to=anaeff}5t tato��dS TEMP POWER FiN� 11JE®
R Lleense Clan Uc.• M,fes - -
Dau ARCHOECIB spLA�a FEB 2 4 2003
I undersand my plan shaM u ll used public rtenrds
Licensed Prof esslocal -
OWNER-BUILDER DECLARATIONa p�
Ii I hereby affirm that i am mempn from tic commences Limn taw for the - B'UI LDING
C a O following mason.(Section 703 1.5,Business and Porlesaions Code:Any city m county
which requimt a permit to conmmct,shm.improve,demolish,or repair my annum
_ Y,+ prior to its issueme,aim required the applicant for such Permit o IM asitned mureem
gZ�}< that he is licensed pursumun Ne provisions of the Conttmtor'sLmnu Law(CNpur9 Sq.Ft.Floor Area "106Ion
C� (commencing with Senion70g0)of Division 3 of the Business and Professions Code)w
BB that he is cumin therefrom and the bash fe,the alleged caemPBon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r 0 Occupancy Type
not more thin Jr.hundred dollen($500}
❑i,m Owner of the property,Or my employees with wgea is their sok compensation,
will do the work,and the net.IS not intended or offered for SAW(Sm.7044,Business — BE
r��S�E Ito
and Professions CoThe Commctoes Limex law coor es napply m an owner or 3 0 4 - ROUGH UTR iYProfessionsne:
propeny who builds m Improved theucon,and who does ouch work himself or through his
own employees,pmvided that such impmwmmts am non inlendeA oroRmnd for role.a,
however,the building or Improvement is Sold widen an year ofmmpletian,the mmer.
builder will haw the burden or pmvint that he did not build or improve for purpose or
❑1,as Owner of Uu property,am reclusively contracting with Retied connctera as
comnn the pmject(Sec.7044.Bushmen and Pfofesdons Code:)The Cnnnimsel U-
mn law does not apply se an owner of property who builds or improves thereon•and
who contacts for such projects with a contractors)Iicend pursuant te the Cme acnets
Lim.Law.
❑I am exempt under Sm. .B&P C for this moan
Dam
WORKERS COMPENSATION DECLARATION
1 hereby alarm order penslty of pcdmy om of the following declarulmu
I have and will maimsm.CenlOcam of Cann)la self-insure fm WmkeYa Compm.
ssllon,u provided No by Section 3700 of the labor Code.fm me pemmmame of that
mark for which this permit h issued
❑I haw and will msintsin WGftes Competition insurance,a required by Sectio
370Dof me labor Code,for the performmm of Um work forwhich this Penn is WOW.
My Works.(��yC�ropeUm t° �° pmes and Polley number arc: -
m ��"�' — �""^ Policy No.: i's
2 701
CERTIFICATE OF EXEMP H)N FROM WORKERS'
COMPENSATION INSURANCE
(This swim nod not he completed i f the lcmll Is foram hundred dollar($100)
or less.) —
I mNfy slut in the pnrfomanm of me wart for which this permll is issued,l shall not
employ any Peron in my summer an as m become Subject M Me Worker'Compensation
4w Of C01f.U.Dau
Applicant
NOTICE TO APPLICANT.If.sMr making this CenlBcare of Exemption,you Mould
become subject w the Worker's Compensation provisions of the LOU,Code.you mum
.,0 fonhwith comply with such provident or this pemll Mail be domed termed. -
„z„tiCONSMUC71ON LENDING AGENCY
(-+ 1 hereby affum that vine is a construction lending agency for the perfaman of
a� the work for which Nis permit is Mixed(Sm 3097,Civ.C.)
Q Lendcfs Name -
e.z Lemices Address;
()0 1 certify that t have read Ws appIkmOft end sou Nu the above information is
LU E~ caner.l agree he comply with all city and county DnErvens and aux law MI Ung to
0 building consmiuMe•and hereby movriat npresmuU.v of this city to enter upon Ne
Wshove-nntiemd property for inspection PufPasea
(We)agree he mw.indemnify and kmP harmless the City or Cupef mo atalml
IIabilhies,Judgments.more;and expenses which may in my my Scenic against aid CityIn emmum or me,Inarmo,or -
. omil
U APPPLLIICCANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR BOULATIONS.
1,2 � Re-roofs
SiLpdme of Applieself0m mnm u
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tic applicant or future building=upset mom or handle hmardum material
m(Mii ed by the Cupenlno Municipal Code.Chapter 9.12,and the Health and Safety
Section 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes NN.
Will the sppmm�t of future banding rampant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hevndnut air conutn u u dermed by me Bay Amo Air Quality Management all-new materials for inspection.
District?
E3
No
1 hes readtie huhaN we maunals mqu immenu under Chapter 6.95 of Urt Ctli for
nia Halm&SatuyCude,Sations15505.15533am 53a.lundersundmuifine builem;
does Out currently have a tent,that 11 is my remomiMllty ve metify me=want of the
require hmust the met missumecer.Crninesear0m Date
� Signature� _ o of Applicant
Owner authon-ura em eat All roof coverings to be Class°B°OI beater