04100181 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �,CO RA.CTOR'IINFORMATION '- - -
......,f
BUILDING ADDRESS: PERMIT NO.
MARVIN DAVIS CONSTRUCTION 04100181
OWNER'S NAME: PERMIT ISSUE DAM
C OL NO.
E: SANITARY
ARCNI'fECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�io0 LICENSED CONTRACTOR'S DECLARATION Job Description
w I hereby affirm Net 1 am IisemN undo woos of Chapter 9 roam a-rang
`: with ion] 0)rf Ddo,,IamE Bameas rofosdaus Co and my lic'mc is
mrdera , aaloci. !/ L� 3 L 'r.0 REVISION--IN HOUSE USE ONLY
jlaz Linen Ldc,.
�t,c Damc°mvactor %Will
NO NEW PERMIT ISSUED/ ORIG. 304060113
ARCHTECI-S DECLAR
I urge{sund my plans"I he used as ds
JaU
Ot, L.cnud PrAmmnal -
5 OWNER-BUILDER DECLARATION
+� 1 hereby affirm Not 1 em cacmpt from Ne Conlmct°rs License Law for the
x p a following return.(Section 703 1.5,Business and Professions Code:Any city ars county
x m which eq.irta a permit tit cofounder.alar,improve,dcmnlish,Or.pair any struaum.
w't^
no,Nis i....cc.alsunequi.Ncapplicant forsdah permit.file s signed samment
�'e Nat he is ficensed pursuant ft provisions of the Comacwr'a License Law(Chapter 9 Sq.Ft. Floor Area Valuati Wl, 15-
Ri- (commencing with Section 70011)of Division 3 err the Business and PmfoUrn,Code)or ?�
that he is exempt therefrom and the basis for the Winged exemption.Any violation of
Sento^7031.5 by airy applicator for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
our mo.than Rro hundred dollar($500).
❑I.ssownon of the pmpeny,or my employcet with wegusslkir sok compenution, 37529007 . 00
will do Ne work and Nestnrctue ianatinaMcd oroRcred fonak(Stt.704a,Busircss
Required Inspections
and Professions Code:The Comuacmfe s License Law Cunot apply m an owner of _ q p
Flannery who buildsarimpr^ves haron,andwho doessuchwurk hlmulforthrodgh his
own cmployses,provided Our such improvements ammo imesded cautioned for We.If. A
however.the building or improvement is sold within one year of completion.the owner-
builder will have dm burden of proving Nat he did not Wild or improve for purpose of 0
sal'.).
❑1,as owner of the properly,am exchtowly contracting with liecosed romracroa to
cmuuuct the project(Sec.lits,Business and Professions Coll The Conlncwr'a Li- -__ - -_-_-_
cense law dras not apply man owner ref properY who Wilds or imp om;thereon.and, - -- - - ---- - — --—--
who contracts for such projects with a contractor(s)Iicenud pursuant to lM Contractor's
License law.
❑I am exempt under Sec. ,B&P C for Nis noon
Owner Dem
WORKER'S COMPENSATION DECLARATION
I herby affirm under penally of pelyury ane of the following declaradmm:
1 hero and will maintain aC'nifiom of Consent to self-instar for Worker'aCnmp'n-
ration,as provided for by Section 3700 of the LaWr Code,for Ne performance of Ne
work for which Nis permit is issued.
0 1 have and will maintain Workers Compensation Insurance.as required by Section
3700 o( CCode rwmprfomnceof Newokfurwhich NisNmitisimued.
WpnsaMy Wo
lnsurancc a//trim and Poli um rare: �,/ -
J�lti'I"L Ff nG Policy q. 7 `I -
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(Thissenium need nothcc°mpk.d If the Permit Is for One hundred dollen(5100)
or less.)
I cenify that In the performance of to work for which this Permit is issued,1 shall not
employ any person in any manncrsn as m become abject to the Workers'Compensation
Laws of California.Dam
Applicant -
NOTICE TO APPLICANT:If,after making Out CeniOcam of Exemption,you should
keome s.bject ro the Worker'.Compensation provisions of the Lahnr COR,you most
�p rundowns comply with such previsions or Nis peork shall W dcemcd evoked.
zN CONSTRUCTION LENDING AGENCY
[-. I hereby alarm that them is a construction lending agency for the performance of
x
the work for which this permit H issued(Sec.3097,Co.C.)
ftJ Q Lender.Name
IL lender's Address
V O 1 certify Nat I lux rtad this application and sum Nat the W.information is
F' Inca I agree to comply with all city and county ordinances and sum laws elating in
ree
�(,7
buildingconstruction.
Agee to and
K.indemniy and keep
hanamliff this city
rCuPemiupon Ne
r W aWK-mentioned properly for ioslection pufposes
G (W')epeemsane,indemnifyandkith hay in an wCityref against said
City
U Z inconseactaceo thecrstsang,cxpcoscswhich may in any wayamuc against said City `1
(J 2 A consequence of the granting of this permit Date
r-, APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCER�AUONs.
i e-roofs
ignmu of pplicanVCanuseful Dam of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant Or future building Occupant store or handle havardous WIWW
az dcaned by tW Cupertino Muni u T Cad'.Chair 19.12 and Ik Health and Safety
Code.Bccuon 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will Nc apPlicent in
future building Occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it honanarms air comamin m.as defined by the Bay Area Air Quality Management all new materials for inspection.
19r1'17
C3 Yes �N`v
I have rtW on hUmil ms materials mquiemens under Chapter 6.95 of Ne Cali for
me Health&Stiffly Codc.Sections 25515,25533 and 25534.1 understand Nat ifthe Wilding
docs not cadontly have a ananr.that it u my responsibility In until Ik occupant of one
reptemens whisibiroteakMCI prior id issuance old Certificate ofOccupency. Signature of Applicant Date
All roof coverings to be Class"B"or better
mer or aurherimd agent Dat.