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CITY OF CUPEWFINO
BUILDING mvIS1ON PI✓RMIT
CONTRACTOR INFORMATION¢
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BUILDINGADDRESS : IIARTHA
MOWRER
rk-U 4040183
OWNER'S NAME:
PERMITISSUEDATE
THA MCWRER
n4/28/2004
TIONS:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MGCH
0 0 0 0
LICENSED CONTRACTORS ot,p DECLARATION
I affirm this I am licensed under provisions of 9 (commencing
Job Description
p
ionhereby70
with Section TtXYJ)ut Division 3nf the Business and Pm&ssiuns Code. and myliccnu is
Code.
inmBmmaand effect.
L fall f Class Lic. p
DD 192 SQ �E'� & RE BED/BATH
Date Contractor
ARCHITECTS DECLARATION
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I understand my plans shall he used as public records
FEB 8 2005
Lteenmd Pmfessmnal
OWNER -BUILDER DECLARATION
1 hereby affirm I am caampl froms the Contractor's Law for Nc
Any
ono
reaso
following reason. (Section 70] L5, Business and Professions Code: Any city or county
an o : c
which mquims a permit In Construct, alley, improve, demolish, or repair any structure
el,nr%O 0
prior d, its I....... lso reqs ms the applicant for such permit to f It a signed statement
the
that he is licensed pursuant m provisions of the Convector's Limnse Law (Chapter 9
SIUIUILAWa 0 0 Vj Valuation
(commencing with Sectio 0(1(0) of Division 3 of the Business and Prormoinns Code) or
Nat he is exempt therefrom and the bass for da alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
356AHtQJ 196na0 Occupancy Type
nos mom than five hundred dollars ($500).
❑ I. as owner of Ne property. or my employees with wages as their sole compensation,
will do she work, and Ne awnure is nos intended or offered for sale (Sec. 70,W, Business
and Professors code: The Contractors License Law does not apply to an owner of
Required Inspections
property who builds or improves flumorf and who does such work himselfer through his
own employees, provided that such improvements art not in¢nded or offered for sale. If.
however, Ne building or improvcmcnt is said within one year of completion. she owner.
builder will have she burden or proving that he did not Wild of improve for purpose of
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sold).
h as owner 4 the properly. am exclusively contracting with licensed contractors to
jdatimuct the project (Sec. 7Osa, Business and Profexsimrs Code:) The Contracmrs Li.
cense law does not apply loan own r of property who Wilds or improves lhemon,and
who can later debt pmjeCuwith acontractoru) licensed pursuant tothe Contnaofa
L' an law.
m B&PC mdo
Div �' D,aL��
.
""AT
WORKER'S COMPENSAT ATION
1 hereby eMw under penalty of pe0ury ane of t e following declarations:
I have and will maintains Cer i0mm of CanwnL 10 self -insure rorworkefscempem
cation, as provided for by Section 3700 of the Labor Cade, for the performance of five
work for which this pewit is issued"
❑ I ban and will maintain Worker's Compensation Ituuntrom. as required by Section
3708 of the Labor Code. for the, performance of the work for which this .I, is issuN.
'
My Worker• Compensation In.... Cartier end Policy number art:
Cartier: Policy NO.:
_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seetioa reN nm W completed if tle pewit is Rimm hundred dollars ($10X1)
or less.)
I cenify that in Ne Performance of the work for which this permit is issued. I shall not
employ any Person in any manner an as to become subject u IMI Workeri Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: IL after making this Ccnirimuc or Eacmption. you should
berome subject to the Workers Compensation provisions of Ne labor Code, you muss
forthwith comply with inch provisions or Nis term is shall bo deemed revoked.
"
CONSTRUCTION LENDING AGENCY
I hereby affirm Nn Dam is • muwctinn lending agency for Inc Performance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
Lenders Name
/
Leader's Address
1 cenify that 1 have read this application and sum that the above information is
correct. I agree to comply with all city and county ordinances and sum laws relining to
Wilding convection, and hereby vutharire mpresenusives of this city to enter Orion the
aMvcmcntioncd for teen puywus.
(We), save.' denimand keep harmles she city of Cupcnino against
iabiliee.,' gmecs anClearers which may in any way accrva regains, said City
Ompairly
nee orga f Nis pa it,PL
ANT A LL COMPLY WITH ALL NO POI
Issued by: Date
SOU ATI
Re -roofs
Data
igwurt or ApplicaHAZA
DO
HAZARDOUS MATERIALS DISCLOSURE �
Type of Roof
Willy orerone
handle broHeal and
"
the Cicant
u defined by Nc Cupertino Municipal Codc, Chapkr 9.13, and the f1calN and Safety
Municure ipal Code,Chaptiame er 9.12, Safety
Cale, Section 35532(.)?
0 Yu
All roofs shall be inspected prior to any roofing material being installed.
Will ma, applicant or future building pend recti dace di
pp g p y pment or devices which
If a roof is installed without first obtainingan inspection, I agree to remove
P
ser ci ardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Dyes
Lha luaa imam smyvirtmcnu under Clumm695of the Califor"
ria Hwl SafctyC 255115. 5)l anJ 255}0.1 undersand thio from Wilding
does t current) e C I n s r¢inillly m nrtily IW an ant of e
mdxlti
myui ntsw Ipn miss �en,cerdre,mmaed r'
Signatore ofApplicant Date
All roof coverings to be Class "B" or better
owner r auNmiled.ga f „e