03010052 CITY OF CUPERTINO
Ruu,Drnc DrvlsloN PERMIT CONTRAC rOR INFORMATION 1a,
3 s�2a:4? .
BUILDING ADDRESS: t PERMITNOO 3010052
i ' 0076 CRESCENT
:R S NAME: PERMIT ISSUE DATE
.:;N WOO 12 O4 2003
NE: SANITARY NO. CONTROL NO.
ARCII1=1ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION
w p I hereby affirm that I am licensed under provisions of Chapter 9(commencing ,. Job Description
�ii with Section 7(0))uf Division 3 oftheBusincsamd Pofessinns Cede.and my license is
in fur force And effeet. ADD 610 S . FT. (2 BR 13 T ARAM S ��*jjj y 1
y viz Liccnsc Class TSD Q ��j( ,1���'(',.�
Da¢ Cumracum '�I\\�kIVI I1 I'f'lL�\u\
££ ARCHITECT'S DECORATION
f C� 1 understand my plans shall M used u public rcamds ,
lyU
Licensed Professional as l
c90g OWNER-BUILDER DECLARATION o1 �V ctOOt�
2 s S I hereby affirm that mm
at I am exempt from the Conacrs License Law for the V 000 L T
00 following ren.($codon 7031.5,Bamocaa and Professions Code:Any city or county
<m(< which requires a Permit or construct,alter,improve,demolish,or repair any structure
°ill prior in its issuance.also requires the applicant for such Permit to file aligned statement
< that he is liecnsd pursuant m the previsions(if the Contractor's License Law(Chapter 9 Sq. Ft. Floor AreaOL ion
2 f=-C (commencing with Section 7")of Division 3 of the Business and Professions Cone)or
4R§ that he is exempt therefrom and the basis for the alleged exemption.Any violation of $86000
Section 7031.5 by any applicant for permit subjects the applicant o a civil penalty of ane APN Number Occupancy Type
not more than Eve bundled dollars(SSW). P Y YP
Q I,as owner of the property,or my employees with wages u onto sole compensation,
will do the work,and the suuaum is not intended 9r offered for sale(Scc.704x,Business 32617036 . 00
And Professions Code:The Contractor's License Law docs not apply w an owner of Required Inspections
property who builds or improves thereon,and whadoes such work himselfor through his
own employees,provided that such improvements are not intended orolfemd for sale.If.
however,the building or improvement is sold within one year of completion.the owner
builder will have the burden of pining Nat he did not Wild or improve for purpose of
ad
Za weer of the property,,B exclusively concocting with:)Theetl contractors t9
sewnthe
ow not apply
Businessand
rtyprofessions Code:)Theves doeors. nd
w roc Law sou notch pir to ts owner of Proper(who med p or improves thereon,dna
who contracts fur such pmjccts with a contractor(s)IittnuO pursuant to the Contractor
Liccnu Law.
1107.1
1 am aempo under See. B&P C fm This maznn
DarWORKER'S COMPENSATION DECORATION
1 hereby affirm under penalty or perjury ore of the following declarations:
ave and will maintain a Cenificam ofComet to self-insum for Worker's Compact
,az provided for by Section 3700 of the Labor Code.far the performance of the
for which this permit is issoeJ.
have anJ will maintain Worker's Compensation Insunntt,az myuimJ by Sccoinn
of the Labor Code,fur the performance of the work for which this Permit is issued.
orker's Cpmpcnsation Inuother cirri.,and Policy number arc:
cr. Policy Nu.:
CERTIFICATEOFEXEMPrIONFROM WORKERS'
COMPENSATION INSURANCE
Chu xniu t need not becompieicd irtk permit is for one hundmd dollars(SIM)
or Icss.)
I certify that in the rarporthance of the work for which this Permit is issued.1 shall nut
employ any Person in any manner.so as or become subject o the Workers'Compensation
Laws of California.Date '
Applicant
NOTICE TO APPLICANT:IL after making this Comfieate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you mum
,Z fonitwi to comply with such provisions or this Iermll shall be deemed¢volum.
Z OCONSTRUCTION LENDING AGENCY
I hereby affirm that there is a commotion lending agency for the Performance of
Z� the work for which this pent it is ismed(Sce.3W7,Civ.C.)
tr-1 Q Lender's Name
,Z Lender's Address
J O 1 trolly Nat f have read this application and trate but the above information is '
Ftorten.l agree to comply with all city and county ordinances and some lases elating to
0 U building consuunion,and hereby authorire mpresentatives of this city to enter upon the
r 4 above mentioned property for inspection purposes.
(We)agree to use.indemnify and keep harmless the City of Cupenino against
FUI liabilities,judgments.costs and expenses which may in any way acerae against said City
U Z in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULp'rAONS. 1
IY�-- W`'-) Re-roofs
iir�
Signature of ApplicaDDate
HAZARDOUS
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Will the applicant all furore building wcupam score or handle havartluus material
effled by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
. Fl Yea 25532(arl All roofs shall be inspected prior to an roofing material being Fl Yea ❑Nu P P Y g g installed.
Will thea applicant or future building occupant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
PP 6 Pam y pmcm or devices which
it hasaNnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
imrict?
QYes 0N
1 have mad the haraNnus materials tequiremeou under Chapter 6.95 of the Calif n.
Am Health K Safety Code,Sections 255)5,25533 and 25534.1 understand thin if the holding
airs not currently hex a foram that it is my responsibility w nnrfy the occupant of the
mgmomn.ntswhich metpnortuisvana�r,cemBeaeufacupaney, Signature of Applicant Date -
Como,or auto nrhe aper f�� Date All roof coverings to be Class "B" or better