05040039 CITY OF CUPERTINO ✓% ^� °-+ �*+ Y�»�> �- "` ``'
BUILDING DIVISION PERMIT CONTRACTnRINFORMATION
BUILDING ADDRESS: PERMIT NO.
05040039
OWNERHTAIF F PERMrI ISSUE DATE
E:
SANITARY0. OL NO.
ARCHITECrfENGINEER: BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION JobDescri hon
wF 1 hereby affirmin thI am licensed under provisions of Chapter 9(commencing _ p
i,u with Stade.Bpl)of Division Sof the Box as and Puffesiona Code.and my license Is
n<u in full forward effect
�'p_ License Class Lle.g INTERIOR REMODEL/BATHROOM/CLOSETS
n k- Dale Contractor -
ARCHITECTS DECLARATION
I understand my plain shall W used as public records
;yu
o Licensed P.hfcesional
OWNER-BUILDER DECLARATION
ilF I hereby alarm thus I am exempt from On Contractors License law for the f +
no following mason.(Section 8131.5,Business and Professions Cole:Any city or county
$ which requires a permit m construct,alter,improve,demolish.or repair any suocmm V ` i t. t 1 ((=_7
tz< prior m its issuance,also requites the applicant forsuch Permit o file a signed statement
that he is licensed Purwannu the provisions.[the Conoacmri License Law(chapter 9 Sq.Ft. Floor Area Vada ion
p~$ (commencing with section 7000)of Division 3 of the Business and Probasiaru Code)or
5- that he is exempt therefrom and dm bnsu for On alleged exemption.My violauonof
Section 7031.5 by any applicant for a permit subjects On applicant to a civil penalty of 3�i�1Ci0 p Occupancy Type
not mom Nan five hundred dollars($5Ny.
❑ I,u owner of the pmport,in my employees with wages as their sole compensation,
will do the work and the structure u not mmnded or offered for sale(See.7014,Business
and Profecumes Code:The Comrxors License law docs a.I apply In an owner or Required Inspections
property who but Ids or improves thereon,and who does such work hi rose If or through his
own employ.,provided that such improvements ase not intended oraffcmd Jerome.If,
however,the building or improvement is sold within one year of completion,dee owner.
builder will have the burden of proving that be did not build or improve for purpose of
tic.).
0 h as owner of the property,am exclusively contracting with licensed contractors to
consumer the Mica(Sec.7014,Business and Professions Code:)The Contracor's Li
come law data not apply m an owner of property who Wilds or ineproaes themon.and
who contracts for such project with a conmemr(s)licensed pursuant In the Convamora
License law.
Of am exempt under ec. B&PC( Nes
Owner Dam
K C ENSATION DECLARATION
1 hereby affnto under penalty of perjury one of the following declarations: -
am and will maintain a Cenificam of Consent m self-insure for WorkersCompcn-
n,as provided Tor by Section 37W of the labor Code,for the o fatmance of the
work for which this permit is issued.
❑1 have and will maintain Workeh Compensation insurance,as required by Section
3700 of the Labor Code,for Oc performance of the work for which this permit is issued.
My Werkeri Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if IW permit is Intone hundred dollars(Slip)
in less.)
I unify that in the performance of the work for which this permit is issued,1 shall not
Laws.anplo,iun,Californiaoninany rpyssa tpbrlgrpa Wblq uo Wort 'Co gone Aswan!Celita .Dam (y_LkL'YYI'glfl(d/DQg�/Irn gl
NOTApplICE
t
NOTICE TO APPLICANT:IL atom making p Certificate or of Exemption,Co,you should
become scoop y the Workers Compensation thin envisions of the toed Code,you must
0 z forthwith comply with such prnviainns or this permit shell W deemed revoked.
Z Q CONSTRUCTION LENDING AGENCY
[-. I hereby affirm Nat there is a coestmoinn lending agency for the performance of
athe wok for which Nis permit is bound(Sec.3097.Civ.C.)
19 A Lenders Nam.
P. Lender's Address
r_1 2
U 0 1 certify that 1 have mail this application and sum Nn the above information is
F-'
crown.I agree on comply with all city and county ordinances and state laws relating to
0 U Wilding construction,and hereby authaxmrepradmativus oftht city in enter upon the
C[l above-memioncd property for inspection purposex
gy (We)agree Io now,indemnify and keep harmless the City of Cupertino against
Hen liabilities,judgment,costs and expenses which may in any way aecmc against said City
U Z in consequence of the granting of this permit.
APPLICANT NOERSTAaN�DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER�1/ 1111/
Re-roofs
Signawr App i aRr Dem
HAZARDOUS
OUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or forumWilding Coe Chaptstow2.handle Health
anmaterial
u defined by the Cupenin u 'creat Code,Chapter 9.i2.and the Health and Safety
CWc.Section 25532(a)T All roofs shall be inspected prior to any roofing material being installed.
I ❑Yu No
Will the epplicanl or f wrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardnus it contami u m Jcfncd by the Bay Area Air Quality Management all new materials for inspection.
ice
0es No
I have mad the hmardnus materials requimments under Chapter 695 of the Califor-
ntoalth&Safay Cook,Statin 35505.25533 and 25534.I understand died ifthe Wilding
notemmn l hove a tenant Nat it is my responsibility m nosily theacupumorthe
irem`nt1 ' c `atco Jg Signature of Applicant Date
Owner tom
m ;<dag�nt oU�t All roof coverings to be Class"B"or better
G