04040130 CITY OF CUPERTINO s•b,. ,,1 s^z �� '^ vex �`�+''' "'' ?:
BUILDING DIVISION PERMIT fiCO NTRACIOR�INTOIZMATION 4'
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BUILDING ADDRESS: PERMIT N`04040130
10280 IMPERIAL AV
'4ER'S NAMG: PERMIT MUB DATE
PERFORMANCE UNLIMITED AUTO SHO Q4120/2004
PHONE: SANITARY NO. CONTROL NO,
ARCIIITEC IENGINECR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
°00 LICENSED CONTRACTOR'S DECLARATION
w 1 bcrcby affirm that 1 am licensed under provixinns of Chapter 9(commencing Job Description
Zwith Section70W)of Division 3 ofthe Business and PromscionsCMe.and my license is
infull force and effea' TI--OFFICE ALTER. /DEMO PAkTl2MA545Wb
y Z License Class Lie.a
aF o Drom Contractor
F l.3' ARCHITECT'S DECLARATION
K-a lunderamndmyplansshallbeusedaspublicrecords JUL
"U 23 2004
0t;;
� Licensed Pmfcasionsl
S OWNER-BUILDER DECLARATION
I 1 hereby affirm that I am exempt from the Contractor's License Low for the t�fl AI�®��
O O following mason.(Section 7031.5,Business and professions Cher:Any city or county
5 m(L which mquims a permit to construct,alter,improve,demolish.or repair any structure 4 8 9
prior it)its issuance,also requires[he applicant forsuch Permit rile asigol statement ®lI,1J
that he is licensed pursuant to the prevision of the Contractor's License aw(Chapter 9 Sq. FL Floor Area Valuation
£F0£
(commencing with Section 7000)o(Division 3 of the Business and Professions Code)or
�Q toot he is exempt Hemline,and else basis for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 3-'12TaQdrAc20 0 Occupancy Type
not more than five hundred dollars(SSW).
R5.4 owner of the property,or my cmploy es with wages as their sole compensation,
will do the work,and me structure is not intended or offered for sale(Scc.7044,Business
and Professions Code:The Contractor's LicenseLaw does not apply to an owner of Required Inspections
,,.,.y who builds or improve thereon,and who docs such work himself or Nmugh his
Own employees.provided that such improvements are not intended or offered for sale.IL
however,me building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve fur purpose of
sale.).
0 1,as owner of the property,am exclusively contacting with licensed convectors to
constmet the project(Sec.7144,Business and Professions Code:)The Contractor's Li.
ceras law does not apply to an owner of property who Wilds or improves mesion,and
who contracts for such projects with a contactor(s)licensed pursuant to the Contractors
License Law.
1 am exempt oder . .BA,P C for this reason
late
�C yr 20=Q(
WORKER'SCOMPE gAT10 ECLARATION
I hereby affirm under penalty of perju one of the following decloatiOna:
I have and will maintain a Certificate of Consem to elf-maure for Workers Compere
sation,as provided for by Section 37M of the labor Code,for the performantt of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
77W of the labor Code,for the performance of do,work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cmnicr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not I¢completed if the permit is for one hundred dollars p$100)
or less.)
1 certify that in the perfomaxc of the work for which this permit is issued.1 shall not
employ any person in any manner sen 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
Without subject to the Worker'a Compensation provisions of the labor Code,you must
,J Z forthwith comply with such provisions or this permit shall W deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
F. 1 hereby affirm mat there is a constructinn lending agency Io tic Performance of
C 7 true work for which this permit is issued(Sec.307',Civ.C.)
t2.1 Lender's Name
=z Lendo's Addax,
U C) 1 cenify that 1 have read this application and state that the above information is
U. F cancel.1 agree to comply With all city and county ordinances and state laws relating to
0U building consvaetion,and hereby amhorim representatives of this city to enter upon the
U>" above mentioned property for ieNction purposes.
(We)agree to ave,indemnify and keep harmless the City of Cars, o against
Iiabilities.judgmens,costs and expenses which may in any way accrue against said City
U Z in consequence of the Sarong of this permit.
^ APPLICANT UN ERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGU ATIONS. I
i 4-�P-0 Re-roofs
ignition, ppiarn Cuntoetor Date
HAZARDOUS MATEXIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanutore or handle hurandous material
sa derated by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
de.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Ye
Will the applicant or future building oaupant use equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir harmdous air contttmimnn a lined by the Bay Arca Air Quality Management all new materials for inspection.
Diudn?
❑Yes u
I have read me hwaNnusmamrials reyvimmentsunder Chapmr6J5 of me Crliful
nia Hca W S Safcty Calc.Scctiom 25505,25533 and 25534.1 undcrsund that if do,Wilding
dares not cemendy ha meant,that it- my aspommility to notify the occurring of me
acquircmenawhi MUSLWmCI nor iamnanfacen;rcaboroccupany. Signature of Applicant Date
All roof coverings to be Class "B" or better
sir au a and ogcm Datc