03120119 CITY OF CUPEWFINO aa' 3✓2 v,�ia '=
�t BUILDING DIVISION PERMIT C®NTRACTOR,INFORMATION
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BUILDINGADDRESS: MARTINN WOODROW PERMIT NO 03120119
OWNER'S NAME: PERMIT LSSUE DATE
MARTIN WOODR W
WE: SANITARY NO, CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION
C I hereby affirm that I am fthe Bu under provisions of Chapter 9(commencing J tl j'jp
U with Sc1 Section 71)(0)affirm
Division 3oflhcaal Busiandness Professions hCode.terand my 9(cmmenci is 9�Osp[V11
j�? m full to=and effect. INTERIOR REMODEL
License Class Lic.N
,gyp Datc Contractor
5a e� K �J �y
~ ARCHITECTS DECLARATION UN V LOO T
1 understand my plans shall W used u public records
J
eau
o G Licensed Professional
5 OWNER-BUILDER DECLARATION B ,I n t{ ss
aS I hcrchy alrrm that I am exempt from the Contractor's License Law for the epv■ L a@a`®'�
0 0 following mason.(Section 7631.5,Business and Pmfesstons Codd:Any city or county
K m which requires a pctmir m cnnstrun,elrer,imprns,Jcmolixh,nr¢pair any mrunum
yai Priono its issuance.also mquirns the applicant for such permit to file a signed statement
6 that he is licensed puruamtothe provisions ofthe Contractor aUmenxLaw(Chapter 9 Sq. Ft. Floor Area Valuation
Y1- (commencing with Section 7BBD)of Division 3 of the Business and Profession Code)or
y $
that he is;exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a petm6 subjects the applicant 10 a civil Penalty Of 3?S410,4ifituO 0 Occupancy Type
our more man 176,o hundred dollars($50o). P Y YP
I,aowner ofthe property,or my employees with wages u thetr.mlc compenatipn,
will do she work,and the structure is not intended oroRered for ale(Sec.704,1,Business
and Professions Code:The Contractor's License law docs not apply to an owner of Required Inspections
properly who builds or improves Hereon,and who does such work himself or through his
own emptoyees,provided that such improvemenu are not intended or offered for ale.If.
however.Ne building or improvement is sold wimin ora year of completion,the owner-
builder will bas the burden of proving Nal he did not Wild or improve for purpose of
Md..).
1,as owner of the propcny,am"elusively contacting with licensed contractors to
conswct the project(Sec.7044,Business and Professions Code:)The Contractor's Li
ave law dao net apply man owner of pmpcny who Wilds or improves themes.and
who contracts for such projeeu with a contractor(a)licensed pursuant in Be Contractors
Wine, raw.
Lpj am ea/[rI}�1]pryll d Or. ,B&P/Cfo-rue this son
Owner
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WORKER'S COMPENSATION DECLA A N
1 WrebY alarm under penalty of perjury one of doe following declarations:
1 has and will maintain a Certificate of Consent to xlfinsum for Worker's Compere
anion,a provided for by Section 3700 of the labor Code,for me performance of IW
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,is,requited by Section
37W of Ne Labor Code,for the ycrformance of the work for which this permit is issued.
My Worker's Com penation Insurance artier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EK EM MON FROM WORKERS'
COMPENSATION INSURANCE
moon section need not W completed dune permit is for Inc hundred dollars(g1IX)
or less.)
I emtify Nat the pe es!t�S�as the work for hia'h N' Pe mitis ismed.1 shall not
employ anya�ninrel toMns ubp ip the Workeri Compcnation
lawsoIca
)J
Applicant n
NOTICE NP 1I,after making this Ccntfcate of Exemption,you should
become subject to the Worker's Compensation provisions of the IaWr Code.you mass
z forthwith comply with such provisions or this Permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
I Wmhy affirm that then its construction lending agency for the Performance of
x dm work for which this permit is issued(Sue.3097,Civ.C.)
W Q tender's Name
Z)
Uz Lender's Address
V Q 1 sonify 0 c 1 have read this application and sura that the ads iws misting is
0 U careen.1 agree rct ro.and wirh all city and euunry ntatnane"and sac¢laws relating e
W aWvcngennswerionand herebyauthon arcprexnutiss of Nis city to toter upon the
4 aMvementioned
re to nY forinspectionan keep ha
(We)agree Ip as,indemnify and trap harmless the City o Cupenst against
E'Iq
Liabilities.1cco nyyutt,cosuand
yyca which may in any way¢etre against Mid City / I
L) z APPLICW NTeUf DERSTAj6SW D WILL COMPLY WITH ALL.NON- DINT Issued by: � Date
SOU EER Gl AT(
S.
Z Re-roofs
gnaum of ApplicamyCDro actor tI?
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant non,or handle hmardous material S
is defined by the Cupertino Municipal Code.Chapter 9.11,and do,Health and Safety :
Code.peen 255321x)+ Nu All roofs shall be inspected prior to any roofing material being installed.
Will Bic. rant or� building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
PP 6 p aAir Qu
t havardnus air contaminants a dcrncJ by the Bay Arca Air Quality Management all new materials for inspection.
D'uvad
❑Yes No
Ihavcread Nehmade aterials reyuimmenu under Chapter 6,95 of the Cali fon
Iia He m&Salt yCodc,Sec- 5505.25533 and 25534.1 undcrsund thmiflhc Wilding
does cmrem have le anL a it is my reaPnnsihililY m nntity n acuP r of the
myu' t m I m prormissuananfacensfica I upaceo Signature of Applicant Date
9r.umurimdageml / Dare All roof coverings to be Class "B"or better