04100067 P CITY OF CUPEWHNO e "-
BUILDING DIVISION PERMIT CO INFORMATION
BUILDING ADDRESS: US ROS INC PERMIT K94100067
0612 CHERYL DR
OWNER'S NAME: PERMIT ISSUE DATE
RICK MAXWELL 640 TAYLOR AVE 10/12/2004
HONE: SANITARY NO. CONTROL NO.
(408) 733-6360
ARCIIITCCf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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L�a LICENSED CONTRACTOR'S DECLARATION ®ODm®
z U F 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Flpl��'
Baa with Section 7tAl6)of Division Softhc Rmoessand Prufessinns Cod and my license is
012= m mBromcaeder t. SL6� REPLACE FURNACE
Ween eclo ❑en
�Fw Da commctur9 20
ARCHIlTCTS DEC TION OCTI 2004
vys s f I understand my plans shall W used as so records
re U
u. Licensed Prnfessinnal Q II II L®
nay OWNER BUILDER DECLARATION
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x'<S 1 hereby affirm that I am exempt from the Contractor's License Law for the
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p o following mason.(Second 7031.S,Business and Pmfeaainns Code:Any city or county
I,$ which requires a Permit us construct,alter,improve.Jcmolich,or repair any structure $2700
Fig prior to its issuance,also requires the applicant for such permit n rile a signed si,ucro nl
that he is licensed pursuant to the pmvitinn,of contractors uanse Law(chapter 9 Sq. Ft. Floor Area Valuation
al Pmarom Being with Section Alta)of Division J of the Business and Professions Cole)ser
i Nal he is exempt themftom and on,basis for the alleged exemption.Any smation of
it
Section 7031.5 by any applicant for d pr subjects me applicant to a civil penalty of
not more man five hundred dollars(3500). b Occupancy Type
0 1,as owner of the propcny,or my employees with wages a their sole compensation.
will do the work.and the strudum is not intended or offered for sale(Sec.7814,Business
and Pmfessmns ante:The Conlnnors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon.and who does such work himselforthmugh his
own mployces.provided that such Improvements are unintended or offered formic,If,
however,one building or improvement is mid within one year of completion.the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7614.Business and Professions Code:)The Contractor's Li.
nu Law does not apply to an owner of property who Wilds or improves theism ,and
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor's
License Law.
0 I am exempt under,Sec, B&P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
I bonny affirm under penally of perjury one.171h.fnllOwiug declarminns:
❑1 have and will maintain a Ccmfinte of Consent to self-insure for Worker's Compcm
nation,as provided for by Section 3706 of the labor Code.for the performance of the
work for which Nis permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as inquired by Section
3700 of the Labor Cwe,for me performance of the work for which this permit is issued.
My Worker's Cnmpensa`y'odlnsumnce carrier and Policy number am: �y
Carrier. TC 1 UND Policy No.;OOIOIphs—�a1f7Y'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not W completed if the Permit is foronc hundred dollars(S IIXl)
nr lcsxJ
I mtifv thw In the(riftumo ncii of the work for which this permit is issued,1 shall not
employ any person in any manner so as m become subject to the Workers'Compensation
Law i of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should
became subject to the Worker's Cam sensation provisions of the labor Code,you must
.J 2 fnnhwi in comply with such provisions or this Permit shall N deemed rcwnked.
z2 CONSTRUCTION LENDING AGENCY
P: I hereby affirm that there is a construction lending agency for the perfurmanec of
0'> the work for which this permit is issued(Sec.YN7,Civ.C.)
Til Q Leukir's Name
z IsnJcr1 Address
J Q 1 anify that 1 have mad this application and sate that the above information is
(yam coned.1 agree to comply with all city and county ordinances and stem laws relating to
building construction.and herehy authorim representatives df this city In enter upon the
UV ahove-menduncd property for inspection purposes.
(Wc)agree to sass,indemnify and it,,,handless the City of Cupertino agamsl
F' h liabilities.judgments.costs and expenses which may in any way accmc against said City /
C.),'� io conn ucncc Of lhegr ting ofthis Permit.
^ APPLI NT UNDER 'in AND WILL COMPLY WITH A NO POINT Issued by: CDale
SOUR EGUL 1 Ns.
Z Re-roofs
DO nater of Appli amlcononcor Dam
III ZARDOUS MATE IALS ISCLOSURE Type of Roof
11 thc applicant or future building sec stare m handle haearduus material
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
ewe.see den 25532(m7 All roofs shall be inspected prior to an roofing material being Installed.
[D Yet ONO P P Y S g
Will mea applicant or[Wore buildin•Occupant use e If a roof is installed without first obtaining an inspection,I agree to remove
PP b p a Air Qu or devices which
mil hvardnus air cnnmminanuazdefined by the Bay Arca Air Quality Management all w materials for inspection.
Dio,KL7
❑Yes 0N
1 have m d me hav rdumr materials requircromb;under Chapter 6.95 of the Cali for.
mat ImKS ty Cook.Secuoos 25505.25533 and 25531.1unJcrsmnd thatif Be Wi10mg
es
doiconic Iy him a tenant that itis my respmobilk,m noery ecu, Iof the
,equi no hien most he incl pm,to issuance of a Ccru Ossa of upanc. Of ICallt e
woe orauthoriscJapcm role Al�roofcoveririgs to lass "B" or better