04020151 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �,EONT-RACTOR,INFORMATION'-
BUILDINGADORESS: ,K DESIGNERS PEa""04020151
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY C NTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
I� = 0
umZ' LICENSED CONTRACTOR'S DECLARATION
°p Job Description
C 1 hereby affirm Nel f am filo,Bd.Mer provisions of Chapter 9(commencing
b with Bcmian 7")of Division3af the Dusinov add Professinm Code.and my license is
^,so in full fometgrrU ������®
iqz LDa.�macl ` colrr $O Y-a VINYL SIDING
n I- LARATION
.-Zomnd my pl m,ml M used uARCHITIECts spublic memo;
FEB 2 3 2004
05 Licensed Professional
5 OWNER-BUILDER DECLARATION
RATION
.�nf 1 hemhy.(Sero that 11. exempt from the Conttanors License Law for nbe ([Q�®I�s[Q1/'�
°° following mason.[Section 7I131.5.Busiss and Pmfessivas Code:Any oily or county BU NG
K$ which mquir.a permit to construct lw,.improve,demolish,or repair any mmaum
m�'^ prior to its issuance.also require the applicant for such Permit o file a signed statement
Nat he is licensed pursuant to pmvisiom of the Contractor's License Law(Chapter 9 Sq. FL Floor Area Valu tion
¢�° (commercial,withSection 7")of Division 3 of the Business and Professions Code)of
i $ that be is exempt themfoom and its,baso for the alleged eumption.Any violation of
Section 7031.5 by any applicant for a permit subjeem the applicant to a civil penalty of 3 �F .y��elp p Occupancy Type
not mom Nan five hundred dollars(5500).
I,as owner of the property,or my employers with wage as ilei to cempcvation.
will de the work and Neswcture u not intended oronered foande(Sec.7064,Business
and Professions Code:The Contrutnrs License Law does not apply to an owner of Required Inspections
propcny who bui Ida or i mprove thereon,and who docs s uch work hi msel f or through his
awn employees.providcd Net such improvements are not intended oroRemd barrels.If.
however,the building or improvement is sold within one year of ecmpktion,the owner,
Wilder will ban the burden of proving that he did not Wild or improve for purpose of
sato.).
❑h as owner of She pmparf,am exclusively contracting with licemed contractors to
convect use project(See.7044,Business and Professions Code:)The Contrxrors U.
cane law docs not apply to an Owner of property who builds at improve thereon,and
who contracts for a seb projects with a cantraetor(s)licensed Pursuant to She Contractors
License law.
❑lameaemptunder See ,B&PCforthismason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 bemby after under pemlty of perjury,ax of the following decluauo d,
1 haw and will maintain a Certificate of Consent in self-insure for WmkersCompen-
sation,as providcd for by Section 3700 Of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compeasafion Imurance,as mquired by Section
3700 of dm Labor Code,for the performance of the work for which Nis permit is issued.
My Workers QorriTssaalion Insurance cabala and Policy number am:
i- V.Y)S7 Policy No.: 1 (. Z
CERTIFICATE OF EXEMPTION MOM 11 KERS'
COMPENSATION INSURANCE
(Thissecurm need not he completed if the permit is for one hundred dollars(Slip)
or loss.)
I certify that in the perfnfmans.of Nc work for which this Permit is issued.l shell not
employ any person in any manner so as as become subject to(be Workeri Compensation
Laws Of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Lahor Code,you must
.,Z foMwirh comply with such prevision or Nis permil shall be deemed rooked.
z CONSTRUCTION LENDING AGENCY
�. Ihemh affirm Nat Nem is a construction lending sen In,the f .of
1—' Y 8 .) eY Per unman
1' the work for which this permit is issued(Sec.3097,Civ.C.)
a 0
Lender's Name
Address
D Z
Q I ttni(y Nat 1 bare mad this application and sou Net the above information is
it,F^ correct,1 time to comply with all city and county ordinances and sue laws missing to
QV building construction,and hereby authorim represemasive ofthis city to enter upon the
}U above-mentioned pmPerty for impccdon purposes. s,
9.1
ree to Saw.
mnify and
dam she
ty of
F' Ta lisbilims.judgemms,roast and`expcme whikicch may In any way ruS.agpfist,said Ory
U z in ting of this Permit.
APPL C `of the St
ANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date r
,SOURCE PfGULATIONS.
LC' I Z C72 Z3 0 Re-roofs
Signature of ApplicanVContractor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Oc applicant or future building Occupant slum or handle h.xS m s material
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Hcalth and Safety
GWC,Section 35532(.)?
pmt able All roofs shall be inspected prior to any roofing material being installed.
kWill the applicant or future building occupant use,equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Diaerin?
❑Yes tau
I have mail Ne monflous materials requirements under Chapter 6.95 of dm Califon
ma Hcaldt&Safety Code.Sections 25505,25533 aru125534.1 understand Nat if the Wilding
dors not curremly how a tenant,than it is my msponsihility m and ly use...p.,of the
requirem whichmuatb.metpriorluiasuanccofaCCrrlc.m fOccupmry. Signature of Applicant Date
iZ 2 — l72/
wnnr or,urh.bedtg.nl Dam All roof coverings to be Class"B"or better