03120089CITY OF CUPERTINO
' ' n vAU ''� "a-'
INFORMATOx
BUILDING DIVISION . PRRMITCQNTRACIOR
BUILDING ADDRESS;
0555 DEODARA DR
PERMIT NO 03120089
OWNER'SNAME:
PERMIT ISSUE DATE
ONE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
C�
LICENSED CONTRACTOR'S affirm DECLARATIONtl•ES
1 hereby that: am licensed under provisions or Chapter 9 (commencing
- fl I�
With Section 7IX10) of Division 3 of Ne Busincv and Pmfmuionsions Code, and my license is
F
in full force and effect.
ADD 574 SQ. FT
License Class Lies
Da¢ Cummer.,
ARCHITECTS DECLARATION t
1 undcrsund my shall be used as records
19 2004
plans public
NOV L•
Licensed Por easianal
OWNER -BUILDER DECLARATION
p p as
I hereby affirm that l am exempt from the Confiscates License Law for the
®�
reamed. ]11]1.5, Business and Pbdessi0re Code: Any tiny county
�■�JtpJ �p�5�tet
whichfollowing emit t or repair any structure
a permit Lir Consumer, improve. demolh s
which ras
prior m its issuance, also squires the aaluc�pplicant famatitt signed statement
is
aisions of for web permit to
Sq. Ft. Floor Area
Va
pr the ice s
(comm islicensed pursuant totheof
ua[lon
eBusinur'snd Prorlsw(Chaptcr9
Division Code)or
(commencing Section 7000) of Division) of
(rot
IBusincssanden. Any
he therefrom and the basis fur the alleged eumpdm. Any violation of
Nal io u
31�N(i WPW grpp
Occupancy Type
P Y YP
Section by any for permit subjccoNeapplicant mscivil penalty of
31.5 b
reddam
than rs(.
not more than rum (;Isms atuaa (SSW).
1, u owner of the pmpmy, or my employees with wages as their sole compensation,
will do the work, and the swaus is not intended or offered for sale (Sec. 7044. Business
Required Inspections
and Professions Code: The Contactors License law does not apply to an Owner of
prarorry who builds or improves thefetn, and who does such week himself or Omagh his
own employees. provided that such improvemcros are not in¢nded or offered for axle. IL
however, the building or improvement is sold within one year or completion. the owner.
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
XL as owner of Ne propeny, am eaelusively comma cting with licensed conuanors to
mart the project (Sec. 7044, Business and Professions Cade:) The Contractor's Li
vc law ams not apply m an owner or property who builds or improve thereon. and
who contacts for such/ withaconmctoga)Iicenudiarauannolhc Conuanora
License Law. /qty
❑ 1 am csempl uaap, S l . a A, P C for thin ream(
„
Ow,0,g
WORKER'S COMPENSATION DECLARAMN
1 rely affirm under Penalty of perjury ane of the fallowing declarations:
1 has and will maintain a Certificate of Consent to ulf-insure for Worker's Compen-
aation, as provided too by Section 37M of the Labor Code. for the perfomtanc) or the
weak for which Nis permit is issued.
1 ban and will maintain Worker's Compensation Insurance, u required by Section
))Ip of Oc Labor Code, for the performance of Ne work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carrier. Poll, No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need no( he etmpleted him fermi( is for one hundred dollars (Slip)
is, less.)
1 certify Nat in The pe,(armmec of Ne work for which this permit is issued, 1 shall nu(
employ any person in any manner m As it) become subject to the Workers Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: It. after making this Ccourri , of Esemphon. You should
become subject to the Worker s Comp)nsarion previsions of the Labor Cadc, you mus(
forthwith comply with such provisions or this permil shall W deemed revoked.
'
CONSTRUCTION LENDING AGENCY
-
I hereby affirm that more is a construction lending agency for the performance of
Ne work for which this permit is issued (Sec. 3097, Civ. C.)
tender's Name
Lender's Address
1 certify that I have read this application and sure that the shout information is
'
correct. 1 agree to comply with all city and county ordinances and some laws relating to
Wilding construction. and hereby authorn< representatives or this city to error upon the
abovcmenlioned property for inspection purposes.
(We) agrees. Live, indemnify and keep harmless the y ac of Cupertino id City
Standing pni7rer hich may in any way accrue against said Cily
-
inconsuposme, of
in ctnscyucncc of the gan)ing this permit.
APPLICANT UN AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
50 RCE REG I
Re -roofs
Type of Roof
Z- 7- 03
Signature of IicanVCtnmotor Or
HAZARDOUS MATERIALS DISCLOSURE
w theaPPlkanlorfumm Wildingmcopanloorenrhandlchavar matoial
as defined by the Cor,minn Municipal Code, Chapter 9.11. and the Health and Safety
)nae, El Yea 255320 41
All roofs shall be inspected to any roofing material being installed.
6.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicam0r mwrebuilding mSupam uuequipment ordevices which
It hanardou.s air contaminants as dcGned by the Bay Area Air Quality Management
all new materials for inspection.
cerin?
❑ yes
(01
(have mal Ne Nrmsmarerials requirements unJcr, Chap¢r 695 of On Cali(on
Iia Health&Seely tons 255(IS. Z5533 arvJ 25534.1 understand Nat ifthe Wilding
d ntr currently Ta tenant, tha(it o my responsibibty m nntily the mcupan(of the
imide upoor toissuance OfaccruficaletrOcapan .
Signature of Applicant - Date
/L /7-c
- All roof coverings to be Class "B" or better
Dwain DareI
amWri>edagent
1