04030063 -7777777'77
CITY OF CUPERTINO '' '"'° " , � "` " `'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
,r
BUILDING ADDRESS: PERMIT NO.04030063 4 0 3 0 0 6 3
10105) DE 70177A PTUD
NER'S NAME: PERMIT LgUE DATE
COLDW
,nONE: SANITARY NoO OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
,Zioo LICENSED CONTRACTOR'S DECLARATION .lob Description
C 1 hereby affirm WI I am licensed under novitions of Chapter 9(commencing
UiNa
gdo.1")of Division Sof m.the Buand Profession Code,and my he.is
^ �' morn sera am erten.
on TI--REARRANGING PARTI/WALLS
7 Ui Z License ClassLk.X
^� Date Contractor CONTRACTOR: BAY VALLEY CONSTRUCTION (03/19/04)
ARCHIIECTS DECLARATION
m-+ 1 uMwgoal my plans l he used as mar
public tB
,aD �/
;oG Licensed Professions]
OWNER-BUILDER DECLARATION
3
+� 1 hereby affirm Nal 1 am exempt form the Convectors License Law for(be Q
i00 following moon.(Section 7031.5.Business and Pmfeeaion Cods:Any city or county
e m which requires a Permit to construct,slog,impmw.demolish,Or repair any mnemic
w-'^ prior to its issuance.also requires the applicant for such permit to file a signed statement
that bis a licendPunmtto the provision.(the Conlnelcr's U..law(Chaper9 Sq.Ft. Floor Area Va [
s � 000
as 1-$ (commencingaI, xe pt Section700(y)it tof he Division r of the Business and Professions Cads)of
.. that he is exempt therefrom and the bats!tar Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not mom dun five hundmd dollars(SSW).
I,a owner of the property,or my employees win wage as their tele eompenadon, 35909017 . 00
will du the work,and the swaum is not intended or offered for sale(Sec.7 W4,Business
and Professions Code:The Contractors License law does not apply In an ower of Required Inspections
propenywho builds or imporm thereon.and whodne such work himselfor Waugh his
Own employee,provided that such improvements are nmintended oroRared for ala.IL
however,the building or improvement it sold within one your of completion,the Owner-
builder will have the burden of proving that Ire did not build of improve for purpose of
e.).
I,as owner of the properly,am exclusively contracting with licensed contractors in
construct due project(Sec.7044,Business and Professions Cade:)The Conommre Li-
Carse law docs not apply ro an owner of property who builds or impravea demon,and
who contracts for such projects with a conoactor(s)licensed pursuant to the Contractors
License Law.
❑ I on excn onder,Bce. .B&P C far this fiction
WORKER'S COMPENSATION DE ON
I hereby afTum under penalty of perjury one at lowing declarations:
thaw and will mainuin a Certificate of Conant to alf-insum for Workers Compen-
sation.a provided for by Section 3709 of the Labor Code,for the Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as required by Suction
3709 of the Labor Code,for the peRurmar a of the work for which this Permit Is issued.
My Workerx Cnmoy it_. s�x�L+ne[ rPo d Po r C i / 3 01-4 T'
FE L, ti
ERTIFlGTE OF FXEMPf10 OM WORKERS'
I vat H Cl COMPENSATION INSURANCE
(rouge Ire re ed not Wcompleed if the Permit is for one hundred dmlh a(Sl W)
or less)
I unify that in the Performance of the work for which this Permit is issued,I shall not
employ any pcou n in any manner an a to become subject o the Worksri CompcntNun
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IC after making this Certificate of Exemption,you should
become suncet to Ne Worker's Comlenation provisions or the Latter Code.you mus
.J Q forthwith comply with such provision or this permit than bs deemed revoked.
ZDsCONSTRUCTION LENDING AGENCY
(-� I herehy domthemconstructionrthat them is a construction lending agency for the psrfurmancc of
FL 7 the work for which this Permit is issued(See.3097,Civ.C.)
ipd Lenders Name
D, Lcndeh Address
U Q I csrtlfy that 1 have mad this application and sum that the about information is
IS. H correct.1 agree to comply with all city and county ominances and state laws relating 10
0U building construction,and hereby authorve representatives of this city to cuter upon the
>" Lu abova.min uortW properly for inspectian purposes.
F' 1 (We)agree in ave,indemnify and keep harmless the City of Cupertino again
N Imaliucapdgmems,costs and expenses which may in any way accrue against aid City
U Z in consequence of the granting of this permit. l/
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINr Issued by: Date
SOU ER GULATIONS.
9 3 1 " / Re-roofs
Sign tum at'ApplicasyCunvacmr Data
HA AROOUS MATERIA 1 OSURE Type of Roof
Will the applicant or future building occupant om m handle havaNuus material
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
"ala Scetion 25532(aT! All roofs shall be inspected prior to any roofing material being installed.
❑Yes Pa
W thea licam or future building t use e I or devices which If a roof is installed without first obtaining an inspection,I agree to remove
PP gby then a AimQ
mit hazardous air conmminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Dbuts
❑Ya '4No
1 have mad the baaamtms materials requirements under chapter 6.95 of the Califor-
niaHwlot&Safety Coca,Sections 25505,25533 and 25534.I underrated thou if W Wilding
docs mol eermney have a tenant that it's my responsibility m notify the occupant of the
m w nmug xTO,pnor lougan f,Cemrate faap ey.rc Signature ofApplicant -- Date
Owns ormlhoriradagenl - t ate All roof coverings to be Class "B"or better