05010067 CITY OF CUPERTINO �t,'
BUILDING DIVISION PERMIT TRACTORINFORMATION
CON,
BUILDINGADDRESS: WATTS CONSTRUCTION PERMITNOO5010067
OWNER'S NAME: PERMIT ISSUE DATE
CALI FINANCIAL HAIR SALON 3941 R N 2005
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: -BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I" LICENSED CONTRACTOR'S DECLARATION
m I nerggby affirm Nal I am littnxd under p Ifions olChapur 9(commencing Job Description
Sand wish cti bIXO fDivimon3of the Busine`es it rofasiom Cade. rdmyliccnuis
=,a L fens ass 4 4;` 1) TI- -NEW HAIR SALON
.)12.Sao License Clues Lic.N
;moo Date Cumonor
ty ARCHITECTS DECLARATION
E C a ` l vndcrstand my plans all c used a Tc vmm c
ids / Ty�(py
C w Licensed Professional
OWNER-BUILDER DECLARATION
'uk s s 1 hereby affirm dial I am c Cmpt from the Convenor's Liccnu Law for the
DO following mason.(Section 7031.5.Business and Purcesum Code:Any city or county O
<m which requires a pconit it)construct,alter,improve,demolish,or repair any avuctum 0
�zi poor oiv issuance,also mquirea the applicant forsuch,amilm rite a signedmatement
a 'bathe isueenud pursuant to the provisions of the contractor s license law(Chapler9 Sq. FL Floor Area Valuation
2,
0 (commencing with section 71(%11 of Division 3 of the Business and Professions Code)or
Q�$ that he is exempt lhcrefrom and Ne basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant to acivil penally of 3 5%TL7` ikiBer0 0 Occupancy Type
not more than five hundred dollars(S500).
❑ 1,u owner of the property,or my employees with wages as their sole compensation,
will do the work,and the xweture is not intended or offered for sale(Sec.70aa,Business
and Professions Cade:The Contractor's License law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or(rough his
motemployess,provided d Lsuch improvements See not intended or offered farsalesM
however,the building or improvement is sold within one year of Compinion,the owner-
builder will have the burden of pmving that he did not Wild or improve for purpose of
Sale.).
❑1,es owner of the propsny,am aclus my contracting with licensed Contractors to
construct the project(See.7044.Business and Profession Code:)The Contractor's Li.
ecnss law docs not apply to an owner or p,.,ny who builds or improves themon,and
who eontnets for such projects with a conteaem,B)licensed pursuant to the Contractor's
License Law,
❑ I am exempt under Sec. ,B&P C for this reason
Data
WORKER'S COMPENSATION DECLARATION
I hereby air,-under penalty of perjury one of the following declarations:
I have and will maintain a Ccnific sec of Consent to self-insure for Worker's Com arn-
sation,as provided for by Section 3IIID of the labor Code,for the performance of the
work for which this permit is issued.
1 ban and will maintain Worker's Compensation Inurma,as mquimd by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Werk C. n � Cartier and Policy.tut"acr int
C Policy No: WO
CERTIFIC OMPE SA INN FROM WO ERS' '
COMPENSATION INSURA
(This xelinn need not hecomplewd if thePeemi�r one hundred dollars(S I9))
nr less.) ,
1 ccryfy that in the performance of the work for which this permit is issued.l shall net
employ any Person in any mannerso as to become subjeu to the Workeri Compensation
Laws of Cith urn it.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
became Subject to the Worker's Compc nation previsions of the Lahor Code,you most
D z forthwith comply with such provisions or this permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby alarm that then,iso conswninn lending agency fonts performance of
:4 de work to,which this permit is issued(Sec.3097,Civ.C.)
Z]Q Lender's Name
1 Unders Add.
Z) z
1 certify that I have mad this application and sum that the 4bon information is
.� coven.1 ague to comply with all city and county ordinances and state laws relating to
U building construction,and hereby aull mprescmatineS of this City to enter upon the
a above mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against S)
r rAy Iiahilihcs,juit 'bene,cusu and expenaes which may in any way acerae againslseid City r
Uz in const nee the g timing of this Permit. /
APPW NT U DER TAND AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOU REGUL TIO S.
Re-roofs
Signora ' Cotnmch" Dam
HAZARDOUS MATERIALSDISCLOSURF. Type of Roof
k1-1Will the applicant or future building occupantat..Or handle haenduus material
as defined by the Cupertino Municipal Cat.Chapter 9.12.and the Health and Safety
Cade,Section 25532(x)7All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the aPPlicam or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit hvardous air contaminants as defined by she Bay Arca Air Quality Management all new materials for inspection.
District) /'
El Yes krl
Ihav mad shaaallous materials myuiremcnts under Chapter 6.95ofdoCalifon-
ma Health&$a rt Cafe,sections 25515,25533 ad 25534 1 understand that ifthe building
mes nm curtenlly an:a rano I:Na it is my responsibility m nndly tlm txcuparit of the
mmentswhic set a lira iaaaane,oraeeedfi,amartReapancy.. .Signature of Applicant Date
Own a seed agent DunAll roof coverings to be Class "B" or better