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CI'PY OF CUPEWFINO',
Bun,nmc DIVISION PERMIT
COO �'TRAGTOR INFQRMATIQN:�'�
BUILDING ADDRESS:
PERMIT N0 41 0 Of 1-6
0305 EL PRADO WY
OWNER'S NAME:
PERMIT ISSUE DATE
ERNA JACKMAN
10/18/2004
NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:BUILDING
PERMIT INFO -
BLDG [LECI' PLUMB MECH
0 0 0 0
DECLARATION
LICENSED CONTRACTORunder
Job Description
Iion7 aflinmthat1am p
P
Division 3urthc Business and professions Code, and my license is
rmsBaunderprnvisinnsofs Code,9mylicenseis
with Section and
in fforce ull ermet.
REPLACE WINDOWS/SLIDING DOOR
License Class Lica
Date Con
DELL
ARCHITECT'S,h.11WuseDECLARATION
1 understand my plans shall be used as public records
/
Licensed Professional
OWNER -BUILDER DECLARATION
1 herchy affirm that 1 am exempt from the Contractor's License Law fur the
0
fullmwing reason. (Section 7131.5, Business and Profcxsions Code: Any city or County
which requires a permit to construct, spin, improve, demolish. or repair any structure
91
poor to its issuance. also requires the applicant for such permit to file a signed statement
FL Floor
-
that he is licensed pursuant to the provisions nrmeContracmri License Law (Chapter 9
Sq. Area
Value'
(commencing with Section 701() ul Division 3 of the Business and Professions Code) nn
that he is exempt theafmm and the Wase fur the alleged exemption. Any violation of
34;PIqR;MbCY0
Occupancy Type
Section 1031.5 by any applicant for a pcnmit subjects the applicant to a Civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner or the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work. and the structure is not intenacd or offered to: sale (Sec. 10,14, Business
and Pmfcssions Code: The COnmactori License Law docs not apply to an owner or
property who builds nr improves thereon. and who docs such work himaclf m through his
own employees, provided that such impfowmcnts arc not intended or offered for arle. IL
however, the building or improvement is sold within one year of completion, the owner.
Wilder will have the burden or proving that he did not Wild or improve for purpose of
xal .).
minoras of the property, am exclusively contracting with licensed contractors to
roomer thpmjcct (Sec. 1044, Business and Professions Code:) The Contractors Li -
se law does not apply m an owner of property who builds or improves thereon, and
who contracts for such projects with a comrselor(s) licensed pursuant to the Contractor's
License Law.
O' 1 am caste t undo Scc. . B & P C for Inis rtaspn
Owner,/��f`L_-i( �aCS C/D Dam 10'� O`I
WORKER'S COMPENS TION DECLAR6TIQN
1 hereby affirm under penalty of perjury one of the Wlbwing declarations:
1 have and will maintain a Cenifitma of Cunsenfto self-iruure fur Worker's Compen-
sation, As provided for by Section 3100 of the Labor Code for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance. as required by Section
3100 of the Labor Code, for the performance or the work for which this permit is issued.
My Worker's Compensation Insurance cartief and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be Completed time permit is for one hundred dollars (SIM)
nr less.)
I certify out In the performance of [tic work for whieb ods remelt is issued. 1 shall nth
employ any person in any manner es as or become subjauo the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, .Bet making this Certificate of Exemption, you should
Increase subject to the Worker's Compensation provisions of the labor Code, you maw
forthwith comply with such provisions on this permit span he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a construction lending agency for the performance of
the work run which this permit is issued (See 3091, Civ, C.)
Lender's Name
Lender's Address
1 ccnethat I have read this application and sure that the store information is
builder I agree m comply were all city and county ordinances dmf sure laws r
construction, and representatives of this bey m enter Doan the
aivexOr upon t e
forms peahen p
above
above mentioned pmperte for inspection
keep ha.
agar m save, indemnify and kith harmless the City of Cupertino against
(we) agree
(s
!/
judgments,
rabmoes,imacorth, dusuang es
may in any way accrue against Cala Cityin
of this mit.
APPLICAN7,�k(YDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REO/ULATIONS.
Re -roofs
Type of Roof
Signal sof ApplicanUConmactur Dao
14AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding nccupent store or huµlle hmanhars material
as dcOned by the Cupenine Municipal Code, Chapter 9.11, and the Health and Safety
CWe. S❑ction 15532RD
-.54.
All roofs shall be inspected Prior to any roofing material being installed.Yds
If a roof is installed without first obtaining an inspection, I agree to remove
g
Will the applicant or future building Occupant use c t or devices which
PP g pan equipment
it hafardsus air contaminants as defined ny the Bay Alex Air Quality Management
all new materials for inspection.
atria?
❑Yes Nn
I have mad Ne hssaardess materials requirements under Chapter6.95 of the Calife .
nits Halth & Safety Code. Section., 25505.35533 and 25.534.1 understand that if the Wilding
Jas our cu dy haw a tenant that it is my nespunsin jot to nW l'y the scrap., of the
-
rtquimntnhichn Wmetpaortoasmmnanf.Cc.Fca'eradup'
Signature of Applicant Date
roof coverings to be Class "B" or better
-'o Date
nermrammmmcaagdnt