03100084 CITY OFC PFWFINO
13uu,mNG OrvISION PERMIT CONTRACTOR INFQRMATION
t BUILDING ADDRESS: PERMIT NO03100084
0 310 0 0 8 4
NEWT NAME: PERMIT ISSUE DATE
JOHN CUT F, VIVIAN TAIANO
JNE: SANITARY NO. CONTROL NO.
a
ARCIIITELTIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 M 0 0
io0 LICENSED CONTRACTOR'S DECLARATION IOb Description
I w 1 hereby affirm Nat 1 am
m licensed under provisions or Chapter 9(comencing P
<ce with Section 7000)Of Division 3Of NC Busineaand Professions Code,end my license is
in full tome and effect.
;'q3 LlamrcClava tie.. DEMO (E) POOL
i F• Date Contractor
i a 1 understand my plans ARA
shall he used s public C]IlTEC77S cord
ad
NOV 2 6 2003
o y
Licensed Pmfcssional
�
OWNER-BUILDER DECLARATION Mw
<i 1 hereby a1Trm that 1 am exempt from do,Contractor's License Law for the BUILDING
UI DINM s
.o o following reason.(Section 7131.5,Business and Prnfesa ims Code:Any city or county V • •
m which requires a Permit In construct,alley.improve,demolish,or repair any structure
alt pnlork,its iSauanCe.alsm Rquiret the applicant forsuch Permit to file a signcd5latcmcnt
< that he is ficouseed pursuant to the provisions Or the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
IFo (commencing with Section 7rXB7 of Division 3 of the Business and Professions Code)or
Nal he u exempt therefrom and Ute basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
Ftat Nanfvchundred dollars($500). P Y YP
( towner of the property,or my employees with wages u their sidecompensation,
sea thework.andtheswaureisnotintendedorofferedforame(Sec.7044.Business 704 — DEMO
rad Professions Code:The Contractor's Licerme Law does not apply to an Owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees.provided that such improvements are not intended or offered forsedc.IL
however,the building of impmvcmcm is mid within am year of eomplednn,the owner-
builder will hate the burden of proving Nat he did not build or improve for purpose of
s.1ale.))
fyn,es ow r of Ne property.a aclusivcly contracting with licensed contractors to
construct the pmjcct(Sia 7044,Business and Professions Code:)The Cardamom's Li
cense Taw docs not apply to an owner of property who Wilds or improve Ihemon,and.
who contracts for such ptoleces with a contncmf(q licensed pursuant to the Contractor's
License Law.
❑I am exemptrap Ccr Scc. .B A,P C for this moon
✓ y /Dirk I C.eA Date 1� D C
W RICEW'SCOMP ATIO�t DECLARATION •
I hereby an=under Penalty of perjuryne oof the following declarations:
#cr
have and will maintain a Certificate of Consent to salbinsum for Worker'sCompen-
Saturn,v provided for by Section 37W of the labor Code.for the pefformana of the
work for which this Permit is issued.
rl 1 have and will maintain Wmkcr's CO n,fro inn[..a.,as roPuirod by Scnion
37W of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
(This section acid nm be completed if the permit is for one hundred dollars(SLOG)
or Itar)
1 certify that in the MTRrnnanee of Ne work for which this Permit is issued.1 shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,of ter making this Cenifcate pf Exemption,you should
become subject to be Worker s Compensation provisions or the labor Code,you mum
D O forthwith comply with such provisions or this Permit shall he deemed revoked.
C CONSTRUCTION LENDING AGENCY
I hereby alarm Nm them is a construninn lending agency fm the Performance of
'L
Our work for which this pomit is issued(Scc.3097,Civ,C.)
3]Q Isndcr's Name
7 z I.cndcri Address
;J Q 1 certify that 1 have read this application and some that he above information is
y E-' correct.I agree to comply with all city and county ordinances and sate laws misting to
DU building construction,and hereby authorise representatives or this city to enter upon the
ahove-mentioned property for inspection PuM=L
y y (We)agree to On.indemnify and keep harmless the City or Cupenino against
Oy liobi lilies,judgments,costs and expenses which may in any way accrue against said City
U Z in easequencc of the gmming of this Permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OURCE REGU{,BTIO^NS`�^ l ^��, /�(o —03
(�"'1 / ( Re-roofs
Signature of Appy UConRDO Dam /. O //n �_3
HAZARDOUS MATERIALS DISCLOSURE Type of Roof (/ CC-�/
Will IAC applicant ti future building e.Chapter
store or handle Health
sdSafrmaterial
u defined by the Cupertino Municipal Code.Chapter 9.11,and the Hcallh and Safety
Idms
. I-1 es zssu(a)r / All roofs shall be inspected prior to any roofing material being installed.
I-1 Yes tt
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haysdnus air conmminants u dchncJ by the Bay Arta Air Quality'management all new materials for inspection.
ict?❑Ycs ❑NIhave read the hmardnus marinate rtyuimntcnts under Chapter 6.95 ofthe Califmr-
calthffiSarctyCode,Secoom 13505.25533 nd25534.I understand that dthe Wilding
not currently haw a mnam.Nat it u my msronsihility m notify tbe acupnt of the
mfnlawhich Most price nissuance orardream o�op�n=yo3 Signature of Applicant Date
Owmer. i..ed micro, /I Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
wDEMO D� /o U CJ P?
CUPERTINO PERMIT APPLICATION FORM
APN# _ �� Date: /
Building Address:
9 is
Owner's Name: -- Phone #:
OHA/ 7 �-c4
Contractor: License#:
Contact: Phone#:
Applicant/Contractor:
Buildjng Permit Info:
le Pur Mec
Job Description:
Residential: �' Ei7Co rcial:
Sq.Ft. Floor Area:
Architect/Engineer: Cl Valuation:
Type of Construction: Occupancy Group:
t . if
1' ble Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
7,3 c —
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