04100170 CITY OF CUPER'I'INOM4 ss -,° `tea .- �a°� 's'?-"°c' :'•
BUILDING DIVISION PERMIT CONTRACTOKINTORMATION
BUILDING ADDRESS JOSEPH & ISABELLA SEGNA PERMIT N04100170
2442 CARNOUSTIE CT
OW NER'S NAME: PERMIT ISSUE DATE
JOSEPH IS: ISABELLA SEGNA 10/26/2004
NE: SANITARY N0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°Oo LICENSED CONTRACTOR'S DECLARATION
a u C I hereby affirm that I am licensed under provisions Of Chapter 9(commencing Job Description f1 nn n
aw with Section
ande)of Division3of me BOsinusand Professions Cnde,and my hccns is I�' � ��h
�„ in laanderreet. CONCRETE STEPS/METAL. HAN tlRdV�1 IIII��—
? Loch. L's.a
r Dam Contra.,
Y ARCHITECTS DECLARATION
I undemond my plans shall be used as puhlic records
DEC /� x3004
` E `
3 a. Licensed Promssionai
`ms OWNER-BUILDER DECLARATION
a S 1 hereby infirm that I am exempt from the Contractor's License Law for the
,0 following reunn.(Section 7031.5.Business and Professions Cwle:Any city or county
u m fgi which squires a Permit it)construct,alter,improve,demolish,or repair any.structure p
Fisptiormi6 issmnce.also requires the applicant for such perm's est file a signednatoment
that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
�Fm (commencing with Secti on 70W)(it Division 3 of the Business and Professions Code)or
to
$ that be is exempt theafrom and me basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjcas the applicant to a civil Penalty of be 0 Occupancy Type
not more than five hundred dollars(SSW).
❑Las ownerof the pmpcny,or my employees with wages u their Sure compensation,
will do the work,and the structure is nut intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law dons not apply to an owner of Required Inspections
property who builds or impmves thereon,end who does such work himself or through his
own employees,provided that such improvcmenO are not intended oroffered for sale.If.
however,me building or improvement is mid within one year of completion.tht owner.
builder will have the burden of proving that he did not build Or improve for purpose of
salt.).
❑1,as owner of the propcny,am exclusively contracting with licensed conoacmrs to
construct the project(Sec.70,14,Business and Professions Code:)The Cummanor'5 Li.
cense law does not apply to an owner or property who builds or improves themon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
,on.
w.
I ,uncia See. Bre PC forthism
Ovncr Date /O a6aaa
WORKER'S COM PENSATION ECIARATI
I hereby affirm undo r penalty of perjury an of dm following dafations:
I have and will maintain a Cenificam of Consent to ul6inwm fur Worker's Coni
.Iran,as provided for by Section 37W of the labor Cade.for the performance of the
work for which this Permit is issued.
❑ 1 have,and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for one performance of the work for which his mrov,is issued.
My Worker a Compensation Insurance Cartier and Policy num her am:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WOR K ERS'
COMPENSATION INSURANCE
(This mcmion need not he completed if the permit is for one hundred dollars(SIfX))
v Iexs.)
1 certify that in the Poformance of the work rnr which this Permit is issued.I shall not
employ any Person in any manner Sir as In Mcumcsu a9tpthe Workers'ComPensation
layws ofiC,�for_arc
WE TO APPLICANT:If,after making this Ce safe Exemption,
of you should
subject to the Worker's Compensation provisions of the Labor Code,you mull
�O forthwi th comply with such provisions or this form i i eMl l he deemed mvakcd.
Z " CONSTRUCTION LENDING AGENCY
I hereby affirm that there isa construction lending agency for the Purfmmancoof
2S i the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lcndcr's Name,
Lenders Address
U Q 1 ceNfy,that 1 have rend this appliCiarm and some that the above informal lan is
F cored.I agree to comply with all city and county ordinances and stale laws relating to
�U building eonsuuaion.and hereby authorize representatives Of this city to enter upon the
r[t7 above-mentianed propcny for inspection purposes.
y (We,)agree m cost,indemnify and keep harmless w y ac of Cupertino against
Fh liabiliti(We)greto casts and expenses and keep may lnany wayty of upertino SaidCity
U in consequence orthe granting of this Permit.
^` APPLICANT UNDERSTANDS AND WIL OMPLY WITH ALL NON-POINT Issued by: Date
SOURC REGULA�TION/S� D /
Re-roofs
.
,.In of ApplicavUCon tractor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store Or handle barardous material
as dcfincJ by the Cupertino Municipal Cudc,Chapter 9.12,and the Health and Safety
Cad,Section 25532(x)7 All roofs shall be inspected prior to any roofing material being
installed,❑Yes �(Nu
Will
the applicant or future building Occupant equipment devices which If a roof is installed without first obtaining an inspection, I agree to remove
v use gunmen or
Oil hazardous air canmm omme,a defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑YCS IdNO
I have road the hmaNaus mosrrisreyuircments under Chapter 6.95 of me Califon
ria Hcalth G Sdcty Cssle.Seedum25N)5.25533 and 25534.1 understand mal if the hviiding
does not currently ha tenant that it ism responsibility m notify the occupant of the
mVmr�which ; ctpor is acerromisof Rseparcy. Signature of Applicant Date
Caner or aathanrnd-agent �- Y`7TH All roof coverings to be Class"B" or better