04040117 ;1-'NFRS
PV OF CUPEWFINO ' 'mr�:"� t� &+x >' t P S' '3 U :=
BUILDING DIVISION PERMIT CONTRACT lR IlNFQRMAT ON r
30S CARTA RIANCA ST
JDR CONSTRUCTION
DING ADDRESS: CO PERMIT Nc04040117
' NAME: PERMITISSUEDATECARLOS & NA 4
E: SANITARY NO. CONTROL NO,
(408) 295-9898
ARCIIITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o
dO,p LICENSED CONTRACTOR'S DECLARATION
r I beret affirm mat 1 em liecoxed under provisions of Chapter 9(commencing Job Description
n2i wimsec i(M)nfDivfvinn3nfdrrT aJy'gxs and Prufesxiuns Code,and mylicense is
_ow in fullb drrfect. o�J
�q> uans.class uca�nZ?i/07j REVISION--IN HOUSE USE ONLY
°,_o Dam contractor NO NEW PERMIT ISSUED/ORIG. 404030208
\ ' A nT:CTS TON
d< Jy xlrmd all be used a ul
,yu _
r.pG I:renscdy'n std .
S OWNER-B IL ER D .ARATIO
ay<3 I hcrehy affirm that 1 am exempt hum to s aor's License Law fur the /
O O following reason.(Section 7031.5,Business and Professions Cale:Any city or county
<m ff which requires a permit to cnnswer,Slier,improve,demolish,or repair any structure
prions its i.centore,aro requires me applicant forsuch permiun Gleasigned statement
�z<
that he islicmuedParanmtlmlireprovmonsOftheCunuarial'sL4mnseLaw(Chapter9 Sq. Ft. Floor Area \ t@ Valuation$34
`yl-$ (commencing with Section 7000)of Division 3 of the Business and Pmfcssions Code)or
that he is exempt therefrom and me basis for Ne alleged exemption.Any violation of Z7
Section 703 L5 by any applicant for a permit subjects me applicant o a civil penalty of APN Number Occupancy Type
net more man Eve hundred dollars(SSW). P Y YP
❑l,as owner of the property,or my employers with wages as meirxom compensation, 32613053 . 00
will dothework,ands: he Comisnali Licem or awdo for sale(Sec.to a4,Business
and Professions builds
ou The Contractor's License taw does not apply ir an owner is Required Inspections
properly who builds or improves chicon,and who docs such work Mmoer through hit,
Own<er,the hs,provided that such improvements wit we not ear of d or mpletio offered for sale. r-
however,the
have the
improvement issoldwithinoneyam of cam forn.theatre of
builder will have the hoiden of proving trial he did not build or improve for PUTose of
sale.).
D I,as owner of the property,am exclusively contracting with licensed conoSctors to
comuuet the project(Sec.7044,Business end Professions Cade:)The Contractor's Li- .
ve taw does not apply to an owner or property who be Ids or im proves therem.and
.mmcu for such projects with a contractor(s)licensed pursuant to the Contractor's
w chose Law.
l am exempt under s .BA,PCf th,.A.on
as Dale (/
✓ K 'O N DEC'ARATIO
JFund, affirm unaerpenanyofierjuryonamme followingdeclaratimns:
1 have and will maintain a Candidate or Consentto self-insure for Worker's Compcm
sation,ar provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is added.
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,Ter me performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy oumMr am:
Cramer: Policy No.:
CERTIFICATE OF EX EM POON FROM WOR K ERS'
COMPENSATION INSURANCE
(This section need not be mmplereJ it the permit is for one hundred dollars olk))
sr Ices.)
1 certify mat in the perfonnsnec of me mk(or bleb this permit is issued,1 shall not
employ any Kromi yndmmdcs rt 'etn d¢Workeri Compensation
Laws of C.hfo Das
App1m /
NOT E T APPLI : a C g this csion Of the
E Labor oo,you should
bcdh lccty the Worker pro Coons or this
provision ft he Lator Code.you must
�Z form ply with such provisions or this permit Shall he decided resolved.
Z OCONSTRUC ION LENDING AGENCY
f-t u-, Ihereby affirm that thea is a consuuction lending agency l or the performance of
C' the week fur which this permit is issued(Sec.3097.Civ.C.)
V] Lender's Nam.
Dz Lender's Address
U C) 1 certify tan I have read this application and Sol that the above information is
F cancer.I agree to comply with all city and county ordinances and sum laws relating to
pU building construction.and hereby euthorim represcautivcs of this city reenter upon the
r (y abovamrahmard property for inspection purposes.
G (We)agree to save.indemnify and keep humlecs the City of Cupertino against
F' rn Liabilities.judgments.costs and expenses which may in any way accrue against said City
UZ in conuyucnce of the gra ins of this permit
'-^ APPLICANT ANDS A D CO Y WIT!{qLL ND POI T Issued by: Date
Rc u s.
Re-roofs
pl V ATA1 OU T Ls DISCLOSURE Da Type of Roof .
Will be applicant or future mguccupum store or handle hasaNuus material
as defined by the Cupertino Municipal Code Cha der 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material beim
installed.D Ycs (6"-
Will
the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nit hvardntu air cmuaminana as didned by the Bay Area Air Quality Management all new materials for inspection.
isoict?
Dyes ,gtm.
1 have mad nth hmaNnusmarerials reyvimments under Chapter 6.95 of the Cshfor-
nisHealthksafctyCOM.Scetlum 255115,25533 and 2553 ndcoured mal drills,fididing
di nmt
ot cmmeally has oral,mat' . res m nndfy lite necup. t of
req" men` sl bcmel s°' ora epam Signature of Applicant Date
0 actor horia.a 0 D/ All roof coverings to be Class"B" or better