04110118 CITY OF CUPERTINO WLVW _ --
BUILDING DIVISION PERMIT CONTRACTOR M
INFORATION
"a BUILDING ADDRESS: PERMITN(T 4 110 118
10184 COL V
OWNER'S NAME: """71/2004
f:RMRISSUE DATE
MARK CABRALES
ONE: SANITARY NO. CONTROL NO.
ARCNr1ECT1ENCINEER: BUILDING PERMIT INFO
MECH
�uoo LICENSED CONTRACTOR'S DECLARATION
1 hereby afrum that 1 am IimazN under pmvuim.of Chapter 9(commencing Job Description
i� with Section)I11N1)of Division 3 of the Boomess aM Professions Code.and my license is -
nflif dcrca qp 1 REROOF—REMOVE EXISTING SHAKE
Z ? License CI s a Lic.x 7. Z l l
n= Dam : Contractor T-C , Cn A�— REPLC W/PRESIDENTIAL COMP - --
ARCHITECT'S DECLARATION
I underatand my plans shall the used as public records J. C . CONSTRUCTION PAID FOR BL 11/18/04
3Ct7 carved professional
3 OWNER.BUILDER DECLARATION
<P I bunchy affirm that I am exempt from the Cimmuctoh License Law far tN
-00 following reason.(Section 7031.5,Business and Professions Code:Anycity or county
x m r which requites a permit in construct.alter.improve,demolish,or repair any someone -- - - - -.
m-'^ prior In its issuance.also requires the applicant for such permit o file a signed statement
Chet o is licensed pursuanl to the provisions of the Conusteri Iden Law(Climber 9 Sq.Ft. Floor Area - Valuation
't-$
(commencingcd
withSeon7")of Division 3 of the Business fes
and Professions Code)or $9000
�
E N.. that o u exempt rortfrom and 0th basis for the alleged exemption.Any violation of $9 0 0 0
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of ane APN Number Occupancy Type
minmom man fiva hundred dollars($5W). P Y YP
I,esownerofth pmpeny,mmyemployaswithwagasastheirmleeompeoadon,
will do the work.and theswctute is nor intended orolfaed for We(See.7044,Businces Required In S
and Pmfenions Code:The ComaanoYa License Law docs net apply m an owner of - q 'speciti If /� II - .-
ownenywhobuildsorimpmsvthimpro meou dnesauch work oroffeortluohis //\\ II 2D
however.me Wildin providedthatsahimpmvemenu am lie intended rroRered the o forms.r- u IDM NALED
however the have
the
b r den of proving that
he didn of year of completion,me owner - - —- -- - - _ - '
builder will have d¢buNen of proving mar o did not Wild or improve for purpose of ----" —
[31.. DEC 1.
❑I.as owner of project
Sec.7 ,am uclusivcly contesting with licensed rontrsws i- �'� 2UU4
maconse La the es not (Sea]DOG,Business and property
who
Code:)The Conhemoons nd
came law deo not apply je an owner of propany who sed p rs improve Contra,and p p tt
who convaetsfor such projects with acontsacmr(s)licensed pursuant in the Convenor's - - - - '- ---" �I' 11�11 ®-� � ll� _
Lice LSw. p CIU I'LL V\\WVIII
am exempt under Sec. .B&P C for mica rtawn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of be following declarations:
I have and will maintain a Canificate of Consent to self-insure for Worker's Compere
silos,az provided for by Section 3]00 of the loon Code,fm the performance of the - -
ork rwhich this permit is issued. -
w have and will maintain Workers Compensation Imurana,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued.
My Workar'e Cnmfor.pN r ce carrier and Policy number am:
Grticr Policy No.:
C ATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section wed not N completed if to permit is for one hundred dollars($IQ))
less.)
1 aril().mat in Use performance of me work for he mix permit a issued.I shall not
employ any person in an mannermuwbge wjgct to tN Workeu'Compensation
Laws of Cali a.Da
ppiica t
r%QnCE TO APP ll;after king this Ccnifcat o option,you should
oa i n suh'cd a the rkc's Compensation previsions the Lima CsoM,you moa
Z z fort�II)�mpI t nvisiom or this permit shat be decmcd mvokcd.
/ ,/OG ONMUCnONLENDINGAGENCY
Fwp hereby affirm mat mere is a construction lending agency for tN performance of
C47 the work for which this permit is issued(Sec.3041,Civ.C.) '
W� a I<ndcr's Name
= Z Lender's Address
V C) I cenify that 1 have mad this application and sone that the aWve information is
U.P comm.1 agree to comply with all city and county onlim noes and mile laws relating in
OU above-mentioned
hereby aetionaer,ousentatives of this city menter upon the
r CL above-(We) 9 pmpcny for inspection purposes
(We)ag a to care,indemnify and keep harmless w City of Cuperonr against
h in consequence
of the gracing of thisex,penses mit. may in any wayaccmc against said City
IJ Z in camequcncc of the Snoring of this permit.
APPLICANT UNDERST OSA WILL COMPLY WITH ALL NON-POINT Issued by: Dat
URCE REGULATI S
at y Re-roofs
avert ofA li Contractor Date
HAZARDOUS MA RIALS DISCLOSURE Type of Roof
ill to applicant or
future build grccupst stem or handle hvardous material
d by do CuKmim Municipal Critic.Chapter 9.12,and the Heads and Safety
C
Sectors 1255320Y7 All roofs shall be inspected prior to any roofing material being installed.
pY _4
Will the applicant or furore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil haaardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes �10
1 have mad the haiiMnsenatenals nequimments under C1bapmr6.95 of thc Califon
ria Health&Safety Code,Smtlum25505.25533 and 25534.1 and nand thmifthe Wilding ,/
d ort cunemly have a v:nam ma it a my rcaponsihilily m noulj the occupant of the / Y d
aiamenis which mus mclp�wissuancc ofa Ccmficatcafomupancv SI attire of Appl icant Date
`' /� `( J y cr amagcm All ro coverings to be Class"B"or better
or Dam