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CITY OF CUPERTINO
CONTRACTOR°INFORMATION "
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT NO.
05030222
OWNER'S NAME:
PERMIT ISSUE DATE
�EE
SANRARY CdIfflol. NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONntACIOR'S DECLARATION
Job Description
at I are licenced under provision of Chapter 9 (commencing
1 hereby affirm Nns
p
wish Section 7") of Division 3 of the Business and Professions Code. and my license is
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L i L'e.Y
30 -DAY TEMP PERMIT
o aro =
Dam Conaartor
9
EXPIRED 04/23/05 (ORIG. #05030110)
ARCHIIECrS DECLARATION
I understood my plans hall he used as public meads
Liconsnd Professional
OWNER -BUILDER DECLARATION
1 hereby alarm that 1 am exempt from the Com acrtir'sLicense Law for the
following reason, (SeNun 7031.5, Business and PmfesioB,Cnde: Any city, or county
which Teem. •perm, w cn.t. altar, improve, dcmidivh, ar repair any amcmre
prior to its issuance. also rtralma the applicant for such pfllnil IO File a signed statement
that he is licensed pursuant w the Provisions of Ne C.o.is.iytnur's UK. U.(Chapter 9.
Sq. Ft. Floor Area Valuation $0 '
(commencing with Section 7000) or Division 3 or ta6tioneasartd Profcan.a. Cboc) a,
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that he is exempt thcmfrnm and the basis far the JRp d'mami n in. Any,violadon of
.
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjccB �hlpiihcum W'itivil Penalty of
not mom than five hundred dollars (5500). - �� (' I //
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2 610
❑ 1, as owner of the pmpeny, or my employco with wages its ei eoltfSNo pensadue.
� `y 0 6 5. 0 0
/ 1
^� ,' Required Inspections
will do the work and theshucture u not intended oroffcred for sake (Sec. Business
and Pmfessiom Code: The Contractors License law does not apply in an owner or
property who builds or improves thereon, and who doessuch work himselfor through his
n employees, provided that such improvements are not intended or amend for sale.Ill
however. Ne building or improvement is mid within one year of completion. to owner.
builder will have the burden of proving Na W w ac did not Wild improve for purpaof
Wilde
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f
0 1, as owner of the propeny, am exclusively contracting with licensed convectors to
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construct site pmjcm (Sec. 7044, Business and Professons Cade:) The Contractor's Li-
cense law does not pply in an owner of property who Wilds or improves thereon. and
who contract for such projects with a conoaotor(s) licensed pursuant In the Conmcim,
LicenseLaw
is on
EIexempt under See. B h P C for Nmas
mexe
TemporaryPermit
Own Dam
Issued prior to plan check completion
WORKER'S COMPENSATION DECLARATION
I hereby aRrso under Penalty of perjury one of the fallowing declarations:
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Contractor and/or Owner accept complete
❑ 1 ban and will maintain a Cenificate of Coneenl to self -insure run WorkersCompen-
swian,pprovidedfafhySection37M.fNelabor Code. forthepcRonnpaofthe
responsibility for correcting additions,
work for which this permit is issued.
omissions and revisions
❑ I ban and will maintain Workers Compensation insurance. sa required by Section
on
37W of the labor cook, for the performauec of the wart for which this permit is issued.
My Wor Compensation lIj,,,rlce d PolicynumMr are:
completed Blue Prints.
carriers
azQ e- iHl�foliryNo.:152Oy 90C4—
Carrier:
Permit good for (30) thirty days
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(finisstttian need not Wcomplemd if Ne Permit is foroue hundred dollars ($I00)
From J
I ¢niN that in the performance of tW work for which Nis Permit is issued, l small not
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empire; any person in any manner so as to meome subject to the Workers Compensation
Signature
Laws of California. Dare
j Date.
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
Worker's the labor Cock.
Wcame subject on the Compensation provisions of you must
ronhwith comply with such provisions in this Permit shall tic deemed revoked.
CONS'DuC' 10N LENDING AGENCY
I hemby affirm that Nem its construction lending ageory for tW performance of
,,, -„ —aa ter_ ,. aaab aa, ,.
the work for which this pemak is issued (Sec. 3097, Civ. C.)
LcndcrS Nano
Lenders Address
I certify that 1 have read this application and stat, that the above information is
correct. I agree to comply with all city and County ordinances and slate laws mlating to
building conswwion. and hereby auNoriM repmsCIAZI a of this City to enter upon the
above-mentioned property for inspection purposes.
(We) agree to pare, indemnify and keep harmlcv the City of Cupcnino against
liabilities judgments. casts and expcn hich may in any way arcmc against mid City
2
in conacqucncc of the granting of th'
APPLICANT UNDER ND WILL COMPLY WITH ALL ON POINT
Issued by: Date
SOU0. L S.
Re -roofs
Type of Roof
2 bS
ocofA V ausn"if
YDem
H ARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm building occupant mom as handle havafdous material
as defined by Ne Cupenino Municipal Code, Chapter 9.12. and the Hcalth and Safety
Code, Section 25532(.)1
❑Yn,s )?-10
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building oaupam use equipment or devices which
mit hanAous air contaminants m dcrieed by the Bay Area Air Quality Management
all new materials for inspection.
Distrietl
❑Inks Na
I have mail on, hasardous matcrmIsrequirements under Chapterit.95 orthe Califor-
niaHeslN6 Safety Coda. Sccdws 255}5:1.5533 and 25534. Iundcrsmnd thatifNc Wirtho,
docs t country h� a tenan4 tpal'(t'n my mapontihility In runty the .111am of the
requirtmem• hidrryYSfbey�nor wimuseceofaccmficamorara ey
Signature of Applicant Date
� ��If<".// 1 ya1
All roof coverings to be Class "B" or better
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