05030218 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION "4
BUILDING ADDRESS: SUMMIT REMODELING PERMITN0050302I'8
OWNER'S NAME: PERMIT ISSUE DATE
GARY
E: SANITARY NO. CONTROL NO.
(408) 377-5252
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� t�
anrOo LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affirm Nm 1 am licensed under previsions or Chapter 9(commencing
U with Section 7")of Division 3 of NC Business and Prufcssions Codc.and my licnuc is
in full from and effect.YJ
License�Iay��O ase., Yr, SQL .. r• REMODEL 2 BATHRMS & LUNDRY RM
Contractor
Da1C_^t/-W
A F t]
ry � A1C1ffiFLTS DECLARATION
I understand my plans shall W used as public records
JyU
30I Licensed professional
. i3 OWNER-exempt RDE the ConTTON
I 1 hereby affirm on 1 am exempt s an the Contractors Co License Law for the
O O which
reason.emmil 1 ]031.5,Business and improve,
de io demolish,
h,or Any city or county
y m which requires a permit no cores the alar.improve,demolish,nr repair any suvaum
prior miu isomed e.also recovercquite thovisiosofo,ou for such Pctor'siccom file a sw(Clned mmcm
Nal mencinnwitpursuantmtheofDivioeoftheContmacasandcnmlaonsCodmr9 Sq. F[. Floor Area Valuation
SFO (commencing with Section 7")of Division)nftW BuziM.<and Probations Code)or
i�g that he is exempt therefrom and the basis for the alleged exemption.Any violation of r-A�D��7v7, ,,aa,,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 5WIRgt�tA M 0 g Occupancy Type
not mom Nan five hundred dollar117 n
❑I,asowncr of Ne property,or my employee with wage asdeir sole compewtlon, (�
willdo the work,and the atrecmre is natimendid or offered forage(Sec.]IN4.Business Required Ins 11 11 Ds
and Professions Code:The Contractor's License law does e not apply to an owner or 9, p
property who builds or improve thereon,and who doessuch work himselfor through his
Own employees,provided Nm such improvements am not intended oroffered facade.If.
however,the Wilding or improvement is sold within on year ofmmpledon.the owner.
builder will have the burden of proving Nat he did not Wild or improve for purymc of
aaic.). �(a
D I.as owner of the property.am exclusively contracting with licensed contractors to ie ✓✓
consumer the prefect(Sec.7014.Business de:)and Professions CoTo,Contractor's Li- M '�
cerise law does not apply to an owner of property who Wilds or improves Ihcreon,and.
who contracts for such projects with a convesewrfs)Iiaved pursuant in the Com=uces (�U
License Law.
❑l am exempt under Sec. B g:P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
1 have and will maintain a Cenificam of Consent to self-insure for WorkefsCompen-
sation.as provided for by Seetion 3]00 of the labor Code,for the Performance of die
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,m required by Statin
3700 of the labor Code,for Ne performance of the work for which this permit is issued.
My,
y Worlds(,s(�e�nrt/y..cnset
fio�p,�nsur_an^cc/foamier and Policy
1number
�am:
...ne-! ,aI
CarrierUft/Ll-gi l'�V/,ss7 Polity Na.:`/�S�g/Vl/f1v'Va�bW
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tits section need not W completed if the permit Is pumne hundred dollars($IIX))
or less.)
I eevily that in the perfmmanee of the work for which this permit is issued.I ha11 not
employ any person in any manncrso as in become subject to the Worlmri ComPenutian
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccniricate of Exemption,you should
become subject to the Worker's Compensation previsions of the Taw Code,you mlw
2 foMwids comply with such provision or this Permit shall W deemed revoked.
Z M CONMUC710N LENDING AGENCY
[-ice I hereby affirm Nat Vert is a construction lending agency for NC Performance of
a the work for which this permit is issued(Sec.3097,Ci,C.)
6W.Q Tandcfs Name '
_z Underi Address
V O 1 cenify that I have read this application and sum that the above information is
(1. i' correct.I agree to comply with all city and county oNinances and sure laws relating to
O V Wilding construction.and hereby autharine representatives of this city to enter upon the
ihove-mentioned Property for inspection purposes.
C~ (We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments,costs and expenms which may in any way scout against saidCity
U rZ in consequence of the granting of this permit.
^' APPLICA UNDERSTA S 1 JI LL COMPLY WITH ALL NON OINT Issued by: Dale
SOUR LA9
TIO T��
ir
/ Re-roofs
sore fAliplicant/contracmr m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or ruum Wilding mcupanl store or handle baaardous maudal
as defirmd by the Cupertino Municipal Code,Chapter 9.11.and the Health and Safra,
Code.section z553z(a)+ /�� All roofs shall be inspected prior to any roofing material being installed.
0 Yea Z5?fN.
Will the applicant or future Wilding occupant usccytipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air contaminants as defined by one Bay A.Air Quality Management all new materials for inspection.
7Di'sirict?
❑Yes No
I have mail the haaard smucrials requirements under Chapter 6.95oftheCali for-
Health S,Safety Code.Scnimu 25505.25533 and 25534.1 undersuM thou iftk Wilding
el oI t1Y have a to ant.N mY repomihilitY u wtifY Ilse oreupanl of dre '
�ior hiiehm�e. ret orate ncatharJca q Signature of Applicant Date
c� (�/t%tZCfri� � �/?
"nerorxuthminc!ageF�� Da�_ All roof coverings to be Class"B" or better