03110117 CITY OF CUPERTINO �.t'
BUILDING DIVISION PERMIT CONTRACTOR INF..ORMATION 4
BUILDING ADDRESS: PERMIT N(0 3 110 117
ER'S NAME: PERMIT ISSUE DATE
IE TSIGARIS 11/20/2003
PHONE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: -- BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
i3oa LI.ih.1I CONTRACTOR'S DECLARATION -
F 1 nonny)form mm 1 am licensed Bu under Piduna of,C.dc. 9(commencing Job DCSGrIp[IDn
with Section]IXN))af Division Jol thcBmincs$)nd Profcuinm Codc.end my license is
+ � in mllto=andeffect. TEMP. PERMIT EXPIR. 12/21/03
;0: LlcenseClasa
Oamun Contract.,
ORIG. #03030090
�= DELL
As shall
use DECLARATION
'>-U 1 understand my plans¢hall M used is public rcenrds
6
5 Licensad Pmfcuinnel
OWNER-BUILDER DECLARATION
00 1 hereby.strum(Sec thin 1 em exempt from the Contractor's License Lew Ibr nW
❑O following reason.(Section ti]1131.5.Businessandmpr improve.
de into Code:Any tiny or county
`4$ which requires n permit tar quirestconstruct.obcc improve,demolish,or repair any nmclum
aZr
prior to issuance.also requires the applicant for such Permit olcasigned snalemcnn
that he is licensed pursuant o the provisionso(the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area VaWddh900
(commencing with Section]IA1()of Division Sof the O usincu and Professions Code)or
i
that he is exempt therefrom and dm basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permiuubjects the applicant to a civil pmothy of APN Number Occupancy Type
not mere man fin hundred d°B"i,($50o). . 36938038 . 00 p y Yp
EI I,as owner of the property.or my employees with wages u their sole compensation,
will do the work,and the structure,is not intended or offered retails(Sec.7614.Business
and Professions Co&:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself orthrough his
own employees,provided Nan such imprownhom,are not intended or offend for tile.If,
however,the building or improvement it send within one you of completion,the owner.
builder wi ave the burden of proving that he did not Wild or improve for purpose of O r Permit
talc.).
s owner of the properly,am exclusively contracting with licensed contractors to
nm.tthe"ro;.en(S e.]O 4.Batin '"°" "''°"'`°°e:,Th.G°"°"`°"`i_ Issued prior to plan check completion
cense law dins not apply to an Owner of properly who builds of improves dom on,and
who canbac or such pmjemz with a connnctorts)licensed pursuant to the Contractors Contractor and/or Owner accept complete
License 4w
filmes InunderSec. r B&P C for this.... responsibility for correctingadditions,
Dole omissions and revisions on
WO KER' SA EC RATIO -
Iherchyeffinnunder n3Ryofperiuryoneof�lowingdrolau.tion): completed Blue Prints.
❑[haw and will maintain a Cenificem ofCmumn to self-insum for Workers Compere Permit g00 nO)tA days .
salion,u provided for by SCcur 3]BO of the labor Code,for the pm(mm)ncc of the
work par which this permit is issued. 11 ""'� /
❑1 have end will..Intel.Wo kort Compensation huusance,as required by Section of Ula From
37M of Ne tabor Code,for the performmee work for which this permit is issued.
My Workers Compentanion Insurance carrier and Policy number art:
' Carrier: Pol icy NO.: Signature
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs section need not W complemd if the pored,it for one hundred dollars(A 100) Date)
..4
fir Icu.)
employ certify Nu in the in any mann of the work for which min thrall is iuucd,l shall nut -
Lawso any person in any manner x as In Wcomc subject the Warkcri Compcnsallon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:Ir' after making this Certificate of Exemption,you should
become object to the Worker's Coons at this
armprevisions1hal of the land Code,you muss
JO forthwith comply with such provisions or mix perminshellWdeemed revoked.
? CONSTRUCTION LENDING AG ENCY
I hereby affirm that there is a Conswction lending agency f or the performance of
0:> the work far which this permit is issued(Sec.3091%Civ.C.)
W0 Lcadcr'a Nem.
0. z0. Lenders Address
U Q 1 certify that 1 have read this application and tum not the above information is
a.F. Correct.I ASOC ro comply with all city and county Ordinances and sum lows relating to
�U building construction,and hereby euthoris represcnulives of this city to enter upon the
W above-mentioned property for impaction purposes.
Lis (We)ngme 1.save,indemnify and keep harmless the City of Corinth.!gains,
r/3 liabilltitt,ju Cost,Co3U• which may In any way acerae against$aid City >�
U z in conxquc cc of the ung of this rain. _ y
^ APPLICA UND STA S D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGULA IONS
Re-roofs
U71
of Applican o r Data
H=Fou MATERIALS DISCLOS Type of Roof
Will the applicant or Room Wilding Occupant store or handle hanudous material
as deBrmd by nW Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
SEl olea lssu(a)]Yes V#K— All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management allnew materials for Inspection.
District]
71 Yea
I have mad the ha obous materials moo torments under Chapter 6.95 of the Califon
Iia Hcal &Safety Code,Secdons25503,25533ud2ss34.lundcraondthuifdlc Wilding no ..ally have a to it is my respomihildy m mmy thnt olcuPtnt of the
tri Cots whichno on rtoissuarecofaccoifi ( pancy. Signature of Applicant Date
a
ter or adthomcd ego D All roof coverings to be Class "B"or better