02100057 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTR'ACT,OR�INFORMATION
BUIrP4e9DRF^ALLENLEAF LA ARGONAUT WINDOW & DOOR PERMIFN92100057
OWIFAssRRANT MICHAEL A AND JANET E 10624 S DEANZA BLVD APPLICATTtpsY"Y2002
AM
IFONI' _74 08) 996-9670 SANITARY NO./ CONTROL NO.
ARCHITECgIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC11
0 0 0 0
w00 LICENSED CONTRACTORS DECLARATION
s O F1 hereby altirm that I am licensed under provisions of Chapter 9(commencing eri Prion
sZ ai se,III Section 70f0)o(Division 3 of NC Business and Professions Code.and my license is WINDOW REPC eI`
LA
_oy
in full Inrec and effect.
cCbux Lich
O a s- Dole o Dole Cumect., /
E'-f,°J ARCHITECTS DECLARATION
eMO / /
��aK lundcrsnd my plans shall used as public records
OaU Of;a Licensed Pmlcssiowl 2
=so
0 OWNER-BUILDER DECLARATION $6500 a p 1 hereby affirm at 1 am exempt from the Contractors License Law Int theal
6 5 0 0
ic S p 0 following reason,(Section 711315,Business and Prefessiona Code:Any a➢y mar county yl
Nawhich requires a Permit 10 commute.alter,improve.demolish.or repair any Structure
va ! prior b)ie isauance,also requires the applicant forxuch permit o file a signed statement
F'=< that he is licensed pursuant to the provisions Of the Connector's License Law(Chapter 9 3S5I9lRa%WAI@fl Valuation
�1-a (commencing with Section 70(q)of Division 3 of the Business and Professions Cods)Err
a 3$ that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fur a permit subjects ter applowel 1.a civil penally of
not more than five hundred dollars($"). 10 2P N PIERS
Occupancy Type
❑I,as Owner of the pruperty,o my employees with wages as their sole compensation.
will do the work,and the structure is not intended or Offered for sale(Sce.7044,Business 1153 —
mid Professions Case:The Contractors License Law does nor apply to an owner of 104 - REBAR Required Inspections
property who builds or improves thereon,and who does such work himself or through his
menemployces.provided thatmchimpruvemenuamnot inwadeduroffetid formic.If. 105 — ANCHOR BOLTS
however,the building or improvement is sold within one year of completion,the owner-
builder will have rhe burden of proving that he did not build or improve for purpose of 106 - SEWER & WATER
sale). 202 — UNDERFLOOR PLUMBING
CA1.as Owner of the progeny,am exclusively contracting wim licensed contractors to 203 — UNDERFLOOR MECHANICAL
construct ct Be Project(Sec.7044.Businessand Professions Code:)The Contractor's Li-
states,Law does not apply it)an owner of property who Wilds or improves therenn,mid 204 — UNDERFLOOR FRAME
Lame,Laaw. mrum
such projects with m ro
licensed Convector's 205 — UNDERFLOOR INSULATION
❑lam escrow�un/d1ol/�k�tee. ,B&P C]or this reason 301 — ROUGH PLUMBING
owner ' x.,64 Date to 7 302 — TUB & OR SHOWER
WORKER'S COMPENSATION DECLAI
303 — ROUGH MECHANICAL
I hereby affirm under Penalty of perjury one of the following declamations: 304 — ROUGH ELECTRICAL
I have and will maintain a Cenificee of Content to self-insure for Worker's CumPen-
sauon,ss provided for by Section 3700 of the Labor Code,for me performance of the 305 - FRAME
work fit' per
an 306 - HOLDOWNS
El I hats and will maintain Workers Compensation Insurance,m required by Section 3 0 7 — INSULATION
3700 of the Labor Code,far me performance of the work for which this permit is issued.
My worker a Compensation assurance carrier and Policy number at 308 — SHEETROCK
Carrier: Put,,N.,: 309 — EXTERIOR LATH
CERT WICA7'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 — INTERIOR LATH
(This section need not teem cid time Permit is for tine hundred dollars(SI(M)) 311 — SCRATCH COAT
I'sunify 313 — ROOF NAIL
employ
the in the n any
of the work for which this Permit is issued,1 shall not 5 01 — FINAL ELECTRICAL ENERGY
employ any Perron in any manner so as m become subject IM WorkersCompensation
LawsCalifornia. a"
Applicant 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT If.after making this Certificate of Exemption,you should 503 — FINAL MECHANICAL ENERGY
Meme subject to the Worker's Compensation provisions of the Labor Code,you must
p Z formwimcomply with suchprovisions Orthis permitshallre,deemed revoked, 504 — FINAL BUILDING ENERGY
z0 CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL
F
I hereby affirm that racre is a corantraiton lending agency]or the Performance Of 506 — GAS TEST
C > thework for which this permitisissued(Sec,3097.Civ.C.)
Lender's Name, 507 — FINAL PLUMBING
W Q
= zLendersAJdress 508 — FINAL MECHANICAL
U O 1 cenify that 1 have lead mis apli emiun and sem mat he above information is 509 - FINAL GRADE
W F correct.l agree to comply with all city and county uNiwnces and sure laws odium,1.
QU
building construction,and hereby mithonse mirmsermitives of this city to enter upon the 5 FINAL PLANNING
r W above-mentioned property(saor inspection purposes. 14 FIN LI W RKS
C (We)agree to w.indemnify and keep hWMICM the City of Cupeninu against
F N pe
liabilities, costs and exnses m
which may in any way amore against said City
U z i o consequence Of the gendng of this pclmir.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATE S. �,f i
la Re-roofs
Signature of Applea it onFnm Dae
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will site applies.,or futon building occupant store or handle hasardous maenzl
as defined by the Capcninn Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25512(a)?
G Yex 19 No All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or future building Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
emit hereNous air coouminints as defined b the Ba Arca meal or devices which g P
r r Quality Management all new materials for inspection.
uisVier7 P
❑Yes ON.
I have read me hara dem.maurials requirements under Chapter 6.95 of the Cannot,
nia Health Nr Safety Code.Securms25505.25533 and 255:si.l understand mznrfde holding
does not currently haw a tenant,mal it is my resrymsibility In rimily the necrp rm of me
icquircmcma which mu Mmcl Poor.,iamorasofs Cenificaeti(0.reupanc.
�„I�aM_'p Jo)7�1 Signature of Applicant Date
Owner in mm ford agent Date All roof coverings to be Class "B"or better