03120041 CITY OF CUPERTINO 7s ". ?r.'t� 3�-�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: C & D FREITAS CONSTRUCTION """'03120041
.R'S NAME: PERMIT ISSUE DATE
SI'IAN
PHONE: SANITARY N6. 0 OL NO.
ARCHITEC tENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°00 LICENSED CONTRACTOR'S DECLARATION Job Description
til FC 1 thereby Option I am liccnvd under provisions of Chapter 9(commencing
7,iW with Section70(111)otDiAsion 3ofdm Business and Norodom Code.and my liemaea is
^its Gifull mmfmceand effeet ADD 709 SQ. FT.
S Liccnu Class Lk.p
Dale-/'a ATyeaa�GanDKL RAT`ONGL
ARCHITECTS DECLARATION
I understand my Plate shall M used u public records
]yU
U. Liccnud Pmfcssianel
OWNER-BUILDER DECLARATION
ny 3 I hereby.sect that I em exempt from the Conlon Ca :Any C Law for the
Xp0 following reason. ermitt 7113L5, r. hm and improve.
deradi Cade:Any city or county
K$�. which rrquira a permit w cnnswn,elle,improv,dcmtdish,nr rtpair any swctum
mem print to its issuance,also exports;the applicant for such permit to file a signed atamnt
me
L'-iexports;exports;< that he is licensed pursuanl'n'he provisions of the Cmanecwr's License Law(Chapter 9 Sq. Ft. Floor Area a t
�N$ (commencing with Section 7")of Division 3 of the Busineas and Profession Craik)or
.. that M is escmpl therefrom and Ne basis for Ne alleged exemption.Any violation of w��n��w
Section 7031.5 by any applicant for a permit subjects be applicant m a civil penalty of 3 MN V H*cjr0 0 Type
not more Nan five hundred dollus
I,u owner of Ne proprrly,or my employees with wages u Ncir sole compensation,
willdo the work and theswemrt is nut humbled or alfmal for sale(Sec.70".Business
and Professions Code:The Contractors License law does not apply in an owner of Required Inspections
propenywho builds or improves tlmreon,and who doosuch work himself or through his
Own employers,provided Nat such improvements are not intended oroRend for sale.If.
however be building or improvement is gold within one year of compledon.be owner,
builder will have the burden of proving Nal he did not build or improve for purpose of
sale.).
I.as owner of the property,am excitnewly contracting with licensed contractors in
conswet the project(Sec.7034,Business and Profusions Code:)The Conu icases Li-
tre Law does not aptly tp an Comer of property who builds or improw>a Nemon,and
who contracts for such projects with a contractor(s)licensed pursuant UG the Conuxlurs
License Law.
❑I am exempt under sm. ,B&PC for Nis moon
el Data
WORKER'S COMPENSATION DECLARATION
1 hereby atBnn under penally of perjury one of the following dcclantion,
1 Nva and will maintain a Certiriae of comenuo self-insure for Wmker'sCompen-
trnn,u provided for by Section 3700 of be labor Cade.for be perfommmtce of the
work for which this permit is issued.
have and will maintain Workers Compensation Insurance,u required by Section
of tha Labor Code,for be performance of be work for which this permit is issued.
y Workers Compensation Insaance anis and Policy number art:
Cartier.SAMAft Policy Nit, )1�?
CERTIFICATEOF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This sealian need not be completed if ie,Icnnil is foranc hundred dollars(SIM)
or less)
1 certify Nat in the performance of the work for which Nis permit u issued,1 shall not
employ any person in any manner go as to became subject in the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis Ccnificam of Exemption,you should
become subject to We Worker's Compensation provisions of the Latter Code,you must
.J Z forthwith comply with such provisions Or Nis Permit shall be dsmcd revoked.
z CON!n RUCT10N LENDING AGENCY
I hereby afire Nat ft.'u•conswninn kndingagmtey for de pert.on once of
(L'
be work for which Nis permit is issued(Sec.3097,Civ.C.)
441 Tabun',Namc
�^ Lenders Address
U O 1 certify that I have mad this application and state Nat be above infmmatiun is
F correct 1 agree to comply with all city and counly oNinanas and sum laws relating to
C U building concoction,and hereby au'cram mpresemadws of Nis city to enter upon the
r•'tl1 above mentioned property for iopecdon purposes.
(We)agsee no save,indemnify and keep hawless be City of Cupertino against
F' N liabilities,judgments,costs and expenses which may in any way aceme against said City
U Z in consequcnee of the Slurring of Nis permit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
g�_ _ /�—' 3 83-nS Re-roofs
� f Alepiicam/Convaam Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store or handle haasromer mammal
^v defined by be Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
C,Section 25532(3)?
�Ya ONO All roofs shall be inspected prior to any roofing material being installed.
-
Will the applicant or fuer building occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haeardous air contaminants az defined by be Bay Area Air Quality Management all new materials for inspection.
District?
D Yes ONO
lit
mad Ne Iwardnus mammials requirements under Clmpmr695 ofthe Calilor
ria Ha1N&Safmy Code.Stttions 25505.25531 anJ 25534.1 unJcrsmnd Nal ifNc building
docs not currently have a tenant that it is my responsibility m notify Nc occupant of the
elnuementswhich...bemit Prior laoaanaof.Certifico,ofOccupancy. Signature of Applicant Date
3/0 sAll roof coverings to be Class"Bt'or better
Owner or arohmined agent Date