04050039 CITY OF CUPERTINO
BUILDING DIVISION PERM C®�VTRAGTCIIZ+INSF,;hR1VIA�N $�
0UILDING ADDRESS: THE WINDOW BROKER PERMIT N134050039
O E NA E PERMIT ISSUE DATE
ONE: SANITARY NO, CONTROL NO.
(Rno) 639-4527
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
_ap LICENSED CONTRACTOR'S DECLARATION Description
>;u G 1 heathy affirm the,I am licensed ua&,provisions of Chapter 9(commencing IoP
bac with Section l0t)u)efOwns..3of00 Businusad Professions Code,antl myhe..he...is
mnr,m de t-
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Licorice CLis. /?-!
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REPLACE WINDOWS
_p Dam DanRN.A
LEU
-Uq an TDECLARATI
cU lundasmy plans shall Muscat
arpuMlcxecorJs
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V f / 2004
o C; Licensed Profcssioml MAY I
` g OWNER-BUILDER DECLARATION
aS, 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ��IIB t�1{�O�
p o j following moon.(Sectian 7031.5,Business and Professions Code:Anycity or smemy UJ D�I,tl
yva� which requires a permit to construct,slier,improve,demolish,or repair any structure 1 g
Flapoor to its issuance,also aquon the applicantfor such permit to file a signed statement
that he is licensed ponoila the previsions of the Coomun's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
pFpCgromancing with Section 7000)of Division 3 of the B usiness and Professions Code)or
i is C that he is exempt thcaBom and Use basis for the alleged exemption.Any violation of
Scvion2031.5 by any applicentfor. emitsubjecu Neapplicmtm&civil pemltyof 32AFNNfftftbe00 Occupancy Type
not mom than five hundred dollars($500). P Y YP
0 I,az owner of the property,or my employees with wages as thcir,sale compensation.
will do Ne weak,and the structure is not intended ar offered for sale(Sec.9044,Business
and Professions Cade:The Contractor's License Law does not apply m an owner of Required Inspections
Property
who buildserimpovcs Oman,and whodorssuch work himselfor thmugh his
own employees,provided Nat such improvements are not intended or offered for sale.If.
however.the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
cuts
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct Ne pmject(Sec.20,4,Business and Professions Code:)The Contractor's Li.
emtse law don not apply to an owner of property who Wilds or improves daemon.and
who concocts for such pmject with a concoctor(s)licensed pursuant o the Contractor's
License law.
0 1 am exempt under Sec .B h P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirn under Penalty of perjury one of no following declaration40 : -
I have and will maintain a Cenifice,c of Continuo self-inxum for Worker's Cempcn-
satinn,as provided for by Section 3700 of the labor Cade,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,u required by Section
3200 of the labor Code,for the performance of th<work for which this pmmit is issued.
My Wor a pen CERjoint[FICAInsumpe-e uric and Policy number aa:
Corti !O WLN/ F VLi 12x1' yOM W0 K R
COMPENSATION INSURANCE
(Test section neOil oar hecompincal if the permit is reran,hundred dollars(SIM)
or less.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workeri Compensation
Laws or Cali fornia.Date
Applicant
NOTICE TO APPLICANT:IL after making Nu Certificate of Excmphm.you should
become subject to Ne Workers Compensation provision of Ne labor Code,YOU must
,..,2 forthwith comply with such provisions or this Permit shall be deemed evoked.
Z O CONSTRUCTION LENDING AGENCY
'r+ Ihereby affirm that there is a construction lending agency for the performance of
C Ne work fur which this pertain is issued(See 3097,Civ.C.)
Lenders Name /
,z Lenders Address
U Q 1 cenify Nat 1 have mad this application and state that the aion information is
I2,^F sono I agree to comply with all city and county ordinances and sum laws relating to
0U building conswctien,and hereby suboriao representatives of Nis city to enter upon Oc
>4 about-mentioned property for inspection purposes.
(We)some to save,indemnify and keep harmless the City of Detention against
Eabilitin,judgments,costs and expenses which may in any way accom against said City
U Z in consequence of the granting a(this permit. kl
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
.9 s r Re-roofs
Sign reef ApplicanVConconor Dam
HAZARDOUS MATERIALS DISCLOSURE�f�� Type of Roof
Will the applinm tar future building occupant sure or hmklMaaefdrus material
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Secdon 25532(.)? All roofs shall be inspected prior to any roofing material being X�Nu
Wm
thea applicant or future building emu ant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
PP 6 p aAirQn
mit haraNnus air contaminants u defneJ by Nc Bay Arca Air Quality Management all new materials for inspection.
District? I -
❑Yes Nu
1 have mad Ne havardous materials requirements under Chapter G95 of thc Califor-
niaHnith&Sofety Cade,Scedons25N)5,25533and2534.1unam=dthaeifthe Wilding
docsrpt Goosed 'have a tenant,Nat it ks my responsibility w notify the occupmt art the
requircmcnmw�isa,., ato "n atoissexace,raC,lrcc.mafoccupancy. Signature of Applicant
Owner m amhonveJ&gem Date
!�+U...t t '�Dole
All roof coverings to be Class "B" or better
iJ
MAY 0 6 20D4
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aptE Owns
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held to Pao', an, va"'LLl
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