04030004 CITY OF CUPERTINO 1 *71 'c W
BUILDING DIVISION PERMIT hSC,ONTRACTORINF.ORMATION
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BUILDING ADDRESS: BAY AREA CUSTOM CONSTRUCTI """04030004
1904 rQR2E MADERA IN
ER'S NAME: PERMIT ISSUE DATE
KEITH
ONE: SANITARY NO. CONTROL NO.
(408) 978-4766
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG E
EE PLUMB MECH
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woZ, LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby affirm Net I am IiamN under Provisions of Chapter 9(Commencing
withsemi,a IXNI ofD"visionJolot e Business and Professions Code.and mylicemc is
full forte an tett
pz Laenma ail REVISION--IN HOUSE USE ONLY
Dam con NO NEW PERMIT ISSUED/ORIG. 03070051
ARCHITECTS DECIA
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cndmyplanssMllheme P
rsurtwrd REVISION--#04020167
U
;OG Licensed Professional
5OWNER.BUILDER DECLARATION
I hereby affirm Nat I am exempt from Ne Contractors License law for the
O o following mason.(Sccdon](131.5,Business and Profcssinm Code:Any city or county
which requires a Permit to cnnuruct,alar,improve,demori h.nr.pair any swcmre
prior in its issuance,also requires ted applicant foruch permit to rile a signed statement
t?'<
that he isliancedpummnuoMeprevision ofMeconwemrsuanYLaw(Chapter9 Sq.Ft. Floor Area Valuation
ad— (commencing with Section TgO)of Division 3 or the Business and Promintions Cods)or
Nat he is exempt therefrom and Ne bmia for the alleged exemption.Any violation of 0
Section 7031.5 by any applicant for a Pewit subjects the applicant to a civil Penalty of APN Number Occupancy Type
rot mo.Nan five hundred dellen(SS k
0 I,as owner of the property,or my employees with wages as their sols compensation,
will do Ne work and the aBucmm is not intended or offered for stem(Sec.7044,Business
and Pormames Code TIm Connor:Liceme taw does not apply to as owner of Required Inspections
progenywho builds or impmvesthereon,and whodoessuch work h dicatfter through his
own employees,provided that such improsvmests arc not intended oroffered formic.If.
however,Ne building or improvement is sold within ane year of completion,Ne owner.
builder will have the human of proving that he did not Wild or improve for purpose of
mk.)
0 I.as owner of the propeny,am exclusively canning with licensed conuactom to �, r
construct the project(Sec.7044,Rusinru and Professions Code:)The Conwcwr's U. )
Cause law does not apply m an owner of propcny who Wilds or improve the.an,and
who Contncu for such pmjecu with a cenwnor(s)licwed Dunuam to the Contractors
License Law.
0 1 am exempt under Sec. .B d:P C far this mason
at Date
WORKERS COMPENSATONDECI RADON
Thereby affirm under penaltyof perjury ou of Me following declarations:
`J I have andwillmeimain eCenifina of Continua sel0insum for Worker's Comr.m
smion,u provided for by Section 37M of the LaWr Code,for Ne pedromm nce of Ne
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of Ne Labor Code,far Ne peRowance ter the work for which his .it is issued.
My Worker's Camra motion Insures¢"artier and Policy mark,
a.:
3
`'�- 4c �-UND poli
CEImRCATEOFE%FN RaOM WORKERS'
c
COMPENSATIONINSURANCE
(Thixeeclian need Out W eamplead if the Permit is Intone hundred dollars(SIM)
or less.)
1 certify that in Me performance of the work for which Nis permit is issued,l shell not
employ any person in any mesner an as to become subject to the Wark of ComPenmdon
Laws ter CalilLroVa.Date
Applicant
NOTICE TO APPLICANT:IL after making this Coalfields of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
.J,Z foMwlth comply with such previsions or Nis Permit shall W accrued revoked.
HCONSRUCTION LENDING AGENCY
I Ws1
by affirm Net there is a construction lending agency Ire Me Performance of
7 the work fur which this .it is issued(Sec.3097.Civ.C.)
W
Lender's Name
6.
Z Landeri Address
U
V Q I ttrree Out 1 have mad this application and sea Net and
above iws oclatiun is
0 U bonding 1 agree to comply with all city and county Ordinances and sum laws slating e
pU building construction,and hereby auNorim¢Prmcnutivu of this city mcnarupon tbe
r W aWve-mentioned property for impaction purposes fi6-Z
F'11
We)agree to save,indemnify and hick homeless;the y ac of against
id City
N
liabilities,judgment,costa andmnify and keep
may lnany wayaccf Cupertino
City
U in consequence of the granting of this Permit.
^� ANDERS7 AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
S
PPLICA gE ngigs�� �Y td I I a� Re-roofs
'Mgcaftim(Z �Pdicarno/Coftxkuo
HAZARDOUS MATERIALS DISCLO URE as Type of Roof
Will the applicant or tutu.Wilding occupant uo.or handle hvamom material
as defined by the Cupenino�M,u(n,ici' pal Code.Chapter 9.13.and the Health and Safety
,jIlLIkom. 25533(x), ta( a All roofs shall be inspected prior to any roofing material being installed.
Yes
Will Nc applicant fuwm building esu equipment erdcvias which If a roof is installed without first obtaining an inspection,I agree to remove
it hanodous air contaminants as defncd by the Bay Ama An Quality Management all new materials for inspection.
Disumi
❑Yes
I have mad Ne hma msm=6alsmquimmenuundcr Chapter6.95arthc Califor
nia UcnWt&Safety Code.Sccdoas 25505,25333 and 25534.1 undersand Naz if Ne Wilding
does not currently have e 4 that it is my mapomihdity a nudfy ted eupam nl dm
mgaimme is bC Iprior missuanccof.C 'Rcaaof -- dy. Signature of Applicant Date
o a I All roof coverings to be Class"B"or better
Ownerti `orixed. D a