05020158 CITY OF CUPERTINOc
BUILDING DIVISION PERMIT sCONTRA ,TOR INFORMATION
auILDING ADDRESS: DPM PROPERTY MANAGEMENT, I T`"T"65020158
OWNER'S NAME: PERMIT ISSUE DATE
DOLLI
I
SANITARY NO. CONTROL NO.
(650) 508-8666ITECTIENGINEER: BUILDING PERMIT INFO
PLUMB MECH
LICENSED CONTRACMIUS DECLARATION
I haroby rtbrm Nat I am lidemcd under provisions of Chapter 9(commencing Job Description
ection 7")ofDivision 3 ofNC Busine and limitation Code,and my license is
rnre andarcea. TI-WALK WAY ADDITION/INSTALL (E) OPENING
j t2�j License Class Lic.p
Da¢ Contractor
ry ARCHITECTS DECLARATION
�i I understand my plans shall be used as politic rends
�yU
3I,t] Licensed Pnsfcssional
OWNER-BUILDER DECLARATION
.�0 0 1 moo .Them on 1 ore exempt from d r Contractors License law for the
p 0 followwhich inn moon.Permi(sectt i ]1131.5.Business and improve.
demolish.
e oli Code:Any afore any
of county
cturc
y$ which its i sa a..astir m enmuuct,alter improv.h perei u or o a sig any awaum
Oat.its Issuance,also nt to the the applicam for such PermrOo Rica signed susmcm
¢F$ (commencing�j< that lim eswit pursuaot to Na provision of theue Busies iLittnselaw(Code)9 Sq. F[. Floor Area Valuation
Outheitswi thenion]fand0 basisofro(NC Businexempts and Profusionsldido or
—
Out he is ecmpt sMmhom and Ne brei for the alleged caemption.Any violation of
Section 703 LS by any applicant for a permitaubjccts the applicant to a civil penalty of 36kIRCNutia-be00 Occupancy Type
not mom than five hundred dollars(8500).
0 I,as owner of she properly.or my employees with wages a their sole compensation.
will do the work and the sweats is net intended m offesud fmsale(Sec.71Nd4,Business
and Professions Coda:The contractors Liam Law does not apply in in owner of Required Inspections
property who Wilelsorimproves thereon,and who docasuchworle himself m Nmugh his
Own emplowes,provided Nat such improvements are not intended oroRerud forsale.It.
however.the building or improwmem is sold within one year of completion.the owner. f
builder will love the burden of proving Nat he did not Wild or improve for purpose of f
0 1,as owner of the property,am exclusively convecting with licensed contractors to
Caeconstruct dpmjea(Sec.]Did.Business and Pro fusions Code:)The Contractors Lid O
Case Law Jou not apply an owner of property who builds or improve thereon,and (�
whence Law.contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
0 1..L
❑I am exempt under See. .B&P C for this recon
Owner Dare
WORKER'S COMPENSATION DECLARATION '—
I haffirm under affirunder tensity of perjury one or the following declansinns:
Chaw and will maintain a Certificate of Consent to self-imam for Worker's Compen.
Mon.u provided for by Section 3700 of the labor Code,for the pmformanee of the
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,u required by Senium
37M of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(Tisscdou reed nos be comple¢d if she Permit is fmone hundred Jellara(8100)
or test)
I¢nifv Nm in Ne performance of Na work for which this Permit is insured.l shall nos
employ any person in any manner so as to become subject to the Worked Compensation
Laws of Califbmia.Das
Applicant
NOTICE TO APPLICANT:If.after making this Comfica¢of Exemption,you should
become subject to Ne Worker's Compensation provisions of the Labor Code,you most
.J O forthwith comply with such provisions or this permit shall W deemed revoked.
Zy CONSTRUCTION LENDING AGENCY
(-. I hereby affirm that there is a construction lending agency I'nr thc performance of
fY the work for which this permit is issued(Sec.309],Civ.C.)
6W.Q Undoes Name
=Z comUndet. Agree t
U O 1 comfy Nat I have read Nis application and sacve Nat Nc above informationteUpne / 5
U 0 cooter I agree to campy with all city and county ordinances and sum laws slating to /V/J//,•Ir`'Js,
U buildingConstruction. hertbyamhon p rposesenutivu or his City mensr upon the
G ahovc(Wo) ical greeproperty for indemnify
ndmnify an keep es. Jam///y//
(We)agreetat an,indemnifyes kith hart in an Na City of =gamin said
J
UTA in judgments,Or grauindof his Permit.
APPLICANT
may in anyway a<cmc against via City O
C.7 z APPLICANTeOf UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date s
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the,applicam or ruwm Wilding oce.pum sW.or handle Health and
=111C,111.1.
defined by dr Cupertino Municipal Code.Chapter 9.11,and Nc HcaIN and Safety
wcSection 35512(x)?
�Ye Otho All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fuws building occupams use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mardmus air contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection.
tell
OYea [D No
1 have road the hvammusmawriab squirements under Chapter 6.95 of Ne Califon
n
Health&SafcyCodc.Sections 25505,15533 about 25534.1 undersand that tithe Wilding
Zdnot currently haw a WOOL than it is my resporsihility m notify the occupant of the
requirmentswhich musabeMCI prior toissuance ofaCertificate ofOccupancy. Signature of Applicant Date
Owner or authomcd agent Date All roof coverings to be Class"B"or better