03090151 (2) Fcrry or CUNsaTwoBUILDING DIVISION PERMIT a.CONTR°ACTORINF®RMATION "kDING ADDRESS: PERMIT"0 3 0 9 0 15 1
'880 ER-ANCO
-R'S NAME: PERMIT ISSUE DATE
I
ION,: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+op LICENSED CONTRACTOR'S DECLARATION
fw F❑ 1 hereby affirm the,I am licensed under provisions of CWpmr 9(commencing Job Description
<W with Section 7000)of Division 3 of the Business and Professions Code.and my licence is .
_oN in full force and effect
>�? License Class Lie.a REWIRING (E) LIGHTS/INSTALL FIRE BELLS
� Dam
ARCHITECTSDECLARATION PIN p p E®
19' I understand my plans shall he used as public records
t,,,u
o„ LiccnmdPntfcssinnel DEC 2 9 2003
5 OWNER-BUILDER DECLARATION
<4 I hereby affirm that I am exempt from the Contractor's License Law for the
o o following mason.(Section 7031.5.Business and Prnfesmmis Code:Any city or county
<m which requires a permit in construct alter,improve,demolish,or repair any swaum
prior to its AYance,also Rquims the aPPIiCdN for such Kmlil to file a Sign ed imNrtlCnt
o
that hcislicensed pursuant talhcprovisions nfthe contractor's License aw(Chapter 9 Sq. Ft. Floor Area aluat)on
es' (commencing with Section 7")of Division 3 of the Business and Professions Code)tar
p $ that he is exempt therefrom and d¢basis for me alleged exemption.Any ,i.l.t nn of 3261005S . 00
Section]031.5 by any applicant for a pumit subjects the applicant o a civil penany of T e _
not more man Five Number _Occuaneve hundred dollars D500). - - - --- .- p y. yp -__
❑1,u owner of the property.or my employees with wages as their suit,compensation,
will do she work.and the structure is not intended or offered for sale(Sec.nun.B uslness _ ,)yS_�. � r.ny,
and Professions Code:The Conoacbr's License Taw dao not apply to an owtmr of 4 H +ee9 ftyns
property who builds or improves Pocono.and who doessuch work himselforNrough his 501 — FINAL ELECTRICAL ENERGY
own employees,provided that such improvements are not intended oroRemd for said.If, SOS — FINAL ELECTRICAL
how she e building of improvement issoldw(fid..a year of crumpled...m.owner
builder will have the burden of proving that he did not Wild or improve for purpo.¢of
7.
L as owner of she PmNrty,;A exclusively consorting with treed it can tnctou to .. _
co met the project(Sec. Busin rad Professions Cod c Conductor's Li-
ss
i-
law does at n owp ray who it mpr.,a thereon,and
who contracts sue ectsw cor(s)In omanuo do Condaemr's
ntt La
❑ am d Sec. PC for n
_
L / Dyyy i9
WORT R'S MPENSATION DECWMVION
' rt,y affirm under penally of pc jury one of the folollawing d strations:
Ive and will maintain a Certificate,of Consent to self-insurefor Worker'sCMmpen-
uti so provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as requiredby Second
3700 of the labor Code,for the performance.(me work for which this Poor it is issued.
My Worker's Compeuation Insurance ca sur and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EX EMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need nor lrcompleted Rod permit is foronc hundred dollars(51(3)
nr less.)
1 Certify that in the performance of mC work for which this Permit is issued.1 shall nut
employ any person in any manner on as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the worker Compensation previsions of the tabor Codc,you must
�zfonM1withcomplywithsuchprovisionsorthiscomitshallWdeemedrevoked,
Z O CONSTRUCTION LENDING AGENCY
L hereby otfrm that there is a construction lending agency for the performance of
x 7 the work for which this permit is issued(Sec.309/.Civ,C.)
QLanders Name
= z Lender's Address
J C) 1 certify that 1 bare read oris aPPBeati.n and sum mat the above information is
3. eonen.I agrce to Comply with all city and county ordinances and state laws relating to
❑U building conduction.and hereby aum.ds representatives of this city to enter union the
aM1consequiocc property for in .ion proposes.
Ya y (We)agree to save,in sonify and keep armless Ih uy of Cupcnino against
ti Iiabilides,judgmc u.co dupe. hie non ay accrue against said City
J z in canscyucnce the ing rift ' er
ti SOURAJ!PLICA G N S
nt/ CAND T CO LY WITH ALL NON-P INT Issued by: Date
ontraetor ?l/ �y Re-roofs
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Ill the applicant or(Mune building occideolikine 9.12,handle Health and
C,Seo by she Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
C,Section 25532(a)7
❑Ye �/� All roofs shall be inspected prior to any roofing material being installed.
s ®No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha,adaus air contaminants as defined by the Bay Arca Air Quality Management
District? all new materials for inspection.
❑Yes
]have= inch- tlnus materials mgwyynncnts rChapmr695 of the Califoo-
nice HcalN glS Y Sec 2505.255yTand2 lundcrstand tharifmc Wilding
to nut cu tly a iyffffY ms a M1tlny to naufy rM acupant of Nc
rt,tarso may A Cupancy -
w yL v Signature of Applicant Date
I u,h.ri.d sgcff Date All roof coverings to be Class "B"or better