05030129 CI BUOF NO
BUILDING DIVISION V PERMIT AV-0 NTRACTOR IANE01 MATI N'
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BUILDING ADDRESS: PERMIT NO.
05030129
jtFNj,S0,f,GTAT-SS BR PERMITL'SUEDATE
E:
SANITARY OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
D O O
u 000LICENSED CONTRACTOR'S DECLARATION
M1 Bunchy affirm'hat I am licensed under provisions of Chapter 9(commencing Job Description
with smile.7004Bof Division Sof do,Dust..and Prof cssiom CMe,andmylimitscis
m In full fow.ml effect.
LicmAvCmar Llc.a ADDITION/REMODEL 935 ' LIVING RM
wFp Date Contractor
7W ARCHITECCSDECLARATION STUDY/MSTRBATH/KITCHEN/BATH
I undentumd my plans shall be used a publie recnnB
Licensed Pmfessinnal F "
OWNER-BUILDER DECLARATION
<S 1 Wish,affirm that I em exempt from the Contractor's License law for the -
00 following reason.(Section?031.5.Business and Professions Code:Any city or county -
$ which requires•Permit o construe',alter,improve.demolish,or repair any structure
FZi prior in its issuance,also requims the applicant for such permit to rile a signed atatemem
£mm that he islic8redpursuant to the provisions ofthe Conmctor'sLicense Law(Chapter 9 Sq. Ft. Floor Area w �� �rlVal ti
F$ (commencing with Section 7000)id Division 3 of the Business and Professions Code)or a paltpg991
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section?031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number ,\ Occupancy Type
not more than Eve hundred dollars($500).
❑Las owncrofshe proputy,tar myemploycuwhh wagnuthcir sole compcnsa'ion, 36924013 . 00
will do Ne work,and the structure is not intended oroffered for laic(Sec.7W,Business - - �-'
and Professions Code:The Conunctor's License Law does not apply to an owner of Required Inspections -
propeny who buildsm improves thereon,and who deessuch work himself or through his
own employees,provided that such improwmenu Intact intended w offered for sale.If,
however.Ne building or improvement is sold wiNin one ycat of completion,Ne owmm-
builder will have the burden of proving that W did not Wild or improve for purpose of
sale.).
❑1,m owner of the pfnrertY am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cade:)The Comment's Li
cense law docs not apply to an owner of property who Wilds or improves Demon,and
who conva,%for such projects with a convacmr(q licensed pursuant o use Contractors
Licens law.
❑IBM exempt unticr cc. B h P nr Is sarin,
Dw r Katal H til o -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
El I have and will maintain a Certificate of Consent o self-insum for Workm'a Cumpcm
sa'ion,m provided for by Section 37W 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,ss required by Section
31W of Ne Labor Code,for the performance of the wmk for which this Permit is issued.
My Wofkces Compensation Insurance carrier and Policy numhef am:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sctiuo nced not W completed If the permit Is Por ane humdmd doll.(51)(1)
or Icss.)
1 certify Not in the performance of the work for which this permit Is issued,l shall not
employany Person m.Ay maprref misccomc subieAt to the Warker5'Cwm satian
Laws of California.Das
Applicant ( r rr
NOTICE TO APPLICANT:IL after making this CeniOcatc of Exemption,you should -
become suhjem to the Worker's Compcmafinn provisions M the Labor Code,you must
O forthwith comply with such provisions or this permit shall the deemed revoked.
Z' CONSTRUCTION LENDING AGENCY
(-+ I hereby affirm that there its construction lending agency for the Performance of
!Yi > the work for which this permit is issued(Sec.3(197,Civ.C.)
UJ0 lsndcr's Namc
=z Lender's Address
V 0 1 certify that I haw read this application and sus that the above information is
D. f•' corms.1 a&=to comply with all city and county on iron es and state laws mlating to
0U building construction.and hereby authorize representatives of this city to enter upon the
r Ck1 above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
F'rap liabilities,judgments,costs and expenses which may in any way accrue Againstsaid City _
V z to consquence,of the gaming of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N NPOI Issued by: Date p2
SOURCEREGULryT'I NS,n '
K-�- N- ��`' Re-roofs e
Signature of Applicar Date
HAZARDOUS
OUS MATERIALS DISCLOSURE Type Of ROOF
Willy t applicant of future Wilding e,Chapter
rmm or hanand le the Health a material
C defined by t25 Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(e)?
❑Yea )p�lf No All roofs shall be inspected prior to any roofing material being installed.
Will the
us applicant or future Wilding occupant use Area
Air Qu or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
moria? tlnuaair comaminan%asJcfmcUbythe Bay A¢aAirQualityManagcmcm all new materials for inspection.
Dinria?
❑Yes 11�No
I have reaU the hazardous materials requirements under Chapter 6.95 of the Califm-
ninHeal"Safety Code,Sections 25N)5.25533 and 25534.1 understand that if Nr.Wilding
does not currently have a le ant,Nat it is my responsibility m nndfy the occupant of the
reyuirtmcn%which Wow issa r c,mE,aenroT�y*�3.m��y Signature of Applicant Date
tea r- ' /�� All roof coverings to be Class "B"or better
Owner of ofibmi,od spent Date