04060222CITYOF CUP-R'I•INO
BUILDING DIVISION PERMIT
CONTRACa''TORINFORMATION,
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BUILDING ADDRESS:
MARTHA MOWRER
PERMIT NOO 4060222
942 FT BAKER D
OWNER'S NAME:
PERMn'ISSUEDATE
MARTHA MOWRER
06/25/2004
, E:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 � L (�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70M) of Division 3 of the Business and Profession Code. and my license is
imfull force and effect.
REVISION--IN HOUSE USE ONLY
License Class L'^"
NO NEW PERMIT ISSUED/ ORIG. 404040183
Dau Conran.,
ARCHITECrS DECLARATION
I understand my plans shill x used as public records
Licensed Professional
OWNER-BUILDER DECLARATION
I hcmb, affirm that 1 exempt arum Um Contrnetors: License.,c Law for Ix
\
following ..on. (Section ] 1. and lou Code: Any city ar entice,
ons" r. alooa
sae. de swment
which ayui,u a permit nh construe, alar, improve. demolish, orfie
in e. asig ed
theapplicanto for such pctorOOicense Law (Chapter
Sq. Ft. Floor Area
Valuatit 107
thar
eis Barmaid pursuant to
(comms cingwitpurwann")ofDislovoftheCom"cursndProelaonsCodmrY
(commencing with Division ian.Codc)Or
the Businessandon.
add
the for the An
Net breis ucmpt dcmfrom and du bnu (or Ix alleged exemption. Any violation of
eraften
APN Number
Occupancy Type
Section 1031.3 by airy applicant for a permit subjects the applicant to a civil penalty of
am marc than fiK hundred dollars (ssoo).
3 5611026.00
1, as owner of the property, or my employe" with wages as dmir tale compensation.
Required Inspections
i do the work and the uructuse is not intended m uffemil outside (Sec. 7044, Business
and Professions Code: The Conuacmrs License law doe, nor apply u .. owne, or
property who builds or improves thereon, and whodmasuch work himself or through his
own employers, provided that such improvements are not intended oroRered for sz4. If.
howew,, the building or improvement is sold within one Icer of completion. Ne owner.
builder will have the burden of proving that he did not Wild or impro.e for purpose of
sale.).
D I, as owner of the property, am exclusively contracting with licensed contractors In
connect d, project (Sec. 700th, Business and Prof",ions Code:) The Contractors LL
cense Law it= not apply to an owner of property who Wilds or improv" demon, end.
who contracts for such projects with a c.nunmr(s) licensed pursuant In the Contractors
L case Law,
our,9,B h PC f.Pia on
_
in
WORKER'S COMPENSATION CLARATION
1 hereby tifihm under, penalty of perjury one of the following dechuminfif
I have and will maintain a CeniGcam of Consent to self-iuum for Workers Compcm
anion, in provided for by Section 3700 of d , Labor Code. for the performance of she,
work for which this permit is issued.
D 1 have and will maintain Workers Compensation brurance. as res imd by Sccton
3700 of use labor Code. for the performance of the wart (.,which this permit is issued.
-
My Workers Cnmpannion Insurance carrier and Policy number am:
Carrier. Policy No,
'
CERTIFICATE OF EKEMPIION FROM WORKERS
COMPENSATION INSURANCE
(Ihusection need not xcompleuJ if the permit is furore hundrddolla" (SIM)
'
or less.)
I ccnify that in the performance of the work for which tis permit is issued. I shall not
employ any person in any nand to become subjauo the Workdor Compcnation
Laws of California. Dell
Applicant
NOTICE TO PPLICANT: If, after making this Certificate of Exemption, you should
become a.bj t m Inc Worker'a Compensation provisions of the labor Code. you mot
forthwith y with such provisions or this permit shall be damcd evakcd.
ON LENDING AGENCY
CONSTRUCTION
thereissued(Scatinntending agency for Bre Performance of
1Wrebyaffirm is a construction
' do work for which d'u permit is issued (S". 3097, Co. C.)
Pe
cra Namc
=
Lenders Addm,s
1 carol, tet I lave mad this application and sou Bras the a Wve information is
' corms I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authmive repmscmatives of this city to enter upon Be
above-mentioned property for inspection purposes.
(We) agree t. save, indemnify and keep harmless du City of Cupertino against
1 limiliti".judgmenu, costs and expenses which may in any way accrue against said City
ineansequcnecofdcgrado o it.
A
' APPL DERSTA AND 1 L COMPLY WITH ALL N N-POI
Issued by: Date
SOU C ATIO
Re-roofs
_ au
Ignawte of Applic
HAZARD OUS MATERIA S DISCLO E
Type of Roof
Will the applicant Or future building Occupant store or handle hazardous material
as defined by do Cupertino Municipal Code. Chapter 9.11, and Bit Health and Safety
code. Soctom 15531(&)?
DYns �ONu
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
will the applicant or future building occupant .,e equipment or device, whim
it havardnn air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
DYes 0
I have mal the harmd aerials requirements under Chapterti.95ofthe Calier-
niaHe Code tion 5,15533 and 2553d.l understand duirthe building
J not curteml ate un tat it' responsibility u nosily IW a pant of
Adms
rots x I or yt,.uane of.ce"fieamoraa cr.
Signature of Applicant Date
/ r.7
All roof coverings to be Class "B” or better
Owner or aamodzea agent o„e