03100188 CITY OF CUPERTINO '�'�''
BUILDING DIVISION PERMIT " CONTRACTOR-INFORMATION U
BUILDING ADDRESS: DREAMWEAVERS PERMIT N0.03100188
0525 DE ANZA BLVD
-R'S NAME: 1491 HICKS AVE PERMIT ISSUE DATE
ABC DEANZA PLAZA 10/27/2003
E:
(408) 286-9299 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±00 LICENSED CONTRACTOR'S DECLARATION ]obDescri tion
1 iz� 1 hereby affirm that l am licensed under provisions or Chapter 9(commencing p
< with Same.70X%1).(Divi'.n 3af Na n.,irmsse fcuinns CnJe.end my licenseis
+ inrullr.me t. [ � REVISION--IN HOUSE USE ONLY
'z Lmase cl {�Lk.a Z NO NEW PMER
ARCHTIECTS OEC`ARATIONIT ISSUED/ ORIG. 403100121
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<a aa22 I areae an h tfa as p.mm mcnw
y
eo Licensed Pmfeui.ne
t OW SER-B LDER DECLARATION
i 1 herebyaffirm this 1am exempt from the Contractor',License Law for the
00
following reason.(Section 703 1.L;Bosoms and vee.COMORCode:Any citystcounty
which requires•permit m cores the alter.improv,dPermit,ri mash any structure
priormim iuuanre.dm reyvircs the applicant for such permitmccosesigned suumcm
< Mal he,is licensed puuuutm0 the provisions of the ContrneLM1 License law(chapmr9 Sq.Ft.Floor Area Valuation $0.
vj S (commencing with Section 7000)or Division 3 of the Budnete and Profeuinns Code)or
that he it exempt theufrom end do basis for Ne alleged eumption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant 10 a civil papally of 3 5kP&&TOW0 0 Occupancy Type
not marc than fin hundred dolbn({500).
❑1,u owner of the property,or my employees with wages a their sole eompenudon,
will do the work and No.uvnu ,is not intended or offered Atlantic(See.7044,Business Required Inspections
and Professions Code:The Contractors Liceme Law deet not apply m e an Owner of q p
property who build.or improve there.M and who don i uch.,it himself or through his
own employees,provided Narsuch improvements see not intended croRered forsalm lf.
however.the building or improvement is sold within one year of completion.Ne owner-
builder will hev the burden or proving that he did not Wild at improv for purpose of _
plc.).
❑1.u awner of Ne properly,am exclusively mesand cantrssi in{with licensed mmrum1.
comma Ne es nota ply in n owro nese and Profession wilds
COde:l The Contractorsn, red
come law dnef not apply je an owner of property,who Wilds or improves Corton,sod,
who contracts for such projects with a eomnn.r(s)licensed pursuant to the Connector.
License law.
I em exempt under Sec. ,B 6:P C for this..on (�
Data C
WORKER'S COMPENSATION DECLARATION `J�
1 hereby afft.uMer pendty,a perjury one of the following declensions: v
an and will mainuin•Certificate of Consent a self-insure for Workee.Compen-
n,as provided for by Section 3700 of the labor,Code,for Ne paromumc of the '
ooh for which Ni.permit Is issued. -
❑I ban and will maintom Wwkeri Compensation Insurance,he notional by Section
J] UborC mthe performanceofa On weak fw QQiyllchp upermit is issued.
37M rCnm t Insunae ars anceof d weakf.%ALolicy hj0
Policy N..:
'CF,RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit it foronc hundred dollen(f lap
or Ins)
I certify Nal in Ne performance of me work for which Nis permit is i itu d,I shell not
employ any person in any muneru as Is,become subject to the Worked Compensation
Laws of C.1ifomia.Dem
Applicant
NOTICE TO APPLICANT:If.after making ON cauricam of Exemption,you Mould
become subject to the Worker's Compenutian provisions of the Labor Code,you mutt
�,Z forthwith comply with such provisions or suis permit shall be deemed ranked,
ZQ CONSTRUCTION LENDING AGENCY
I hereby.m.that fere it.conslrucdmt lending agency for the performance of
i> the were for whim this Permit i.issued(sa.3W7,Civ.C.)
ir Lenders Name
z Landa.Add..
;)0 I ccnify that I haw mad this application and sum Nat Oc Dhow brOMaliun is '
y F COMICIL 1 agree to comply with all city and county on inmces and rate laws relating On
V building construction,and hereby auaorim mpmtonmins of Nil city m enter upon me
„ a shove-mentioned propony(w impecuon purposes.
y (We)ague to uv,indemnify and gap humleu the City of Copeman emsl
N Ilablhda,judgmenW costs and expenses which may in my way eKNe again id City
J7 inc.nsegance of the granting of this permit.
rr��.• APPLICANT UNDERSTANDS AND WILL COMPLY WITH -POINT Issued by: D
SOURCER TIO
°2-7 Re-roofs
Signup a cruc O.cl& Dam
HA RDOUS TERIA IS DISCLOSURE Type of Roof
dl Nc epplinmwluwm Jing wcupam port or handle hanrd.m material
defined by Ne Cupertino Manic tl Code.Chapter 9.13.and the HmIN and Safely
Section zss32(.)7 All roofs shall be inspected prior to any roofing material being installed.
E]Yet o
Will the applicant or fulu uilding Cceupanl use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
henNom air cor.bas ms JeOad by Ce 8ry A.Air Quality Management all new materials for inspection.
Idd.
in7 fY//
❑Yes Nu
Ill reed the haaardnus mLcridarcquimmenmuuler Chapmf 95o(thc C.hrmr.
caiN'Safety Cadc,Swuou2550s,25533 and 25534.1undcn dwifCm iliing
not c ntly hew a one Nat it is my rcaponsihilfym nod I`�ar�cctsc I of the
mme wren pd.rmismmce.f.Cc a Signature of Applicant Date
e A
Owner orawhomsJ agentam All roof coverings to be Class"B"or better