04020021 CITY OF CUPERTINO + 'awA ' %
BUILDING DIVISION PIl RMI'1' =xCONTRACTOR INTORMAT ON 1w
._v�.. .
BUILDING ADDRESS: PERMIT NO0 4 02 0 02 1
10301 JOHNSON
OWNER'S NAME: PERMIT ISSUE DATE
AS CU T.R. 04/13/2004 v
NE: SANITARY NO. CONI ROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
trop LICENSED CONTRACTOR'S DECLARATION Ih Description
F❑ I heresy affirm com
,hal 1 am licensed under provisions of Chapter 9( menciOIP
ng
6th With Scetim,700B of Diviss
xiun3ufmcBusincand Profcssinns Codc.and my license is
I. seta anderrc9t SFDWL-2 STORY/LIVING 1/ 815��
Door Class Lic.X e ® �C®
a
Door—n,ntmem. GARAGE 479 SQ FT -f�WY tdrw
pp� ARCHITECrS DECLARATION
�C-r l understand my plans shall to used is pWllencoN,
Liccnud Pndcssianal DEC Q
Loi ! ZOO/.
S OWNER-BUILDER DECLARATION
T
1 hereby strum,hat 1 am exempt from Ne Contractor's License Law for the
se a following reason,(Section 7031.5,Business and professions Code:Any city or county
I
m which requires a permit m construct,alter,improve,Jemnli,h,or repair any structure
°iy Poor o its issuance.also reyuisa the applicant for such permit to file aligned statement
roc
that he is licensed pursuant it)Ite provisions(if the Contractors License Law(Chapteri? Sq. Ft. Floor Area
xIa (commencing wi th Section 7000)of Division 3 of the Business and Professions Cods)or
s. Nat he is exempt therefrom and the basis for to alleged exemption.Any violation of
Section 7031.5 by any applicant for a peemh Subjects he applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(S500). 37518033 . 00
O 1.a owner of the property,or my employees with wages as their ante co sfamea,ion.
will do the work.and We swchme is not intended or offered for sale(Sec.7014.Business
and Professions Code:The Cononsor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who dues such work himself or through his
own cmploycu,provided that such improvements are not intended oroffered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
buildcr will ve the burden of proving that he did not Wild or imFrow for purpose of
sale.).
.as owner of be progeny,am exclusively contrxting with licensed contractors to
nsudn the project(See.7044,Business and Professions Code:)The Contractors Li.
se Law Cors not apply to an owner of property who builds or improves motion,and
who contracts for such projects with a comranos(s)licensed pursues,to the Contractor',
License I.W.
0 m 1 aacre t under Sec. .B A,P,C foe Nis..on
tvncf Date
'WORKERS COMPENSATION DEC TION
1 hereby under penalty of perjury one of t allowing declarations:
[have. aiintain a Cenificmc of Consent to self-insure for Worker's Comp:m
ration,as provided for by Section 37M of the Labor Code,for the performance of the
work for which his fermi,is issued.
0 1 have and will maintain Worker's Compensation Insurance,in required by Section
37M of the Labor Cade,for the performance of the work for which Nis Permit is issucd.
My Worker's Compensation Insurance carrier and Policy nummer are:
Cartier: Policy No.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section aced not he completed tithe Permit is for one hundred dollars($Hkt)
of less.)
1 certify War in We ferfomanee of the work for which this permit is issued,I shall not
employ any reuse any promor 0 as to Wc comsubject so the Workere Compensation
Laws of California!Da¢ -
Applicant
NOTICE To APPLICANT:If,after making this Certificate of Exemption,you should
became suhject to the Worker,Compensation Provisions df the Lour Cndc,yno must
., rZ forthwith comply with such Provisions or Permits hall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[r 14 1 hereby affirm that Were is a construction lending agency l'or the performance of
Rim We work fur which this permit is iesued(See 301)?.Civ.C.)
UJ 0Lenders Name
2 z Undeis Add..
V O 1 certify that 1 ban read this application and state that We above information is
ly P const.1 agreed comply with all city and county ordinances and stoic laws totaling to
0O building construction,and hereby authorise representatives of Nis city to let upon the
r W above mentioned Fiercely for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
i,) Iiabilitirajudgmcnts,costs and expenses which may in any way&come against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EREGULATON( _5.
V(NL•/ Re-roofs
I r (Applicant/Contmeor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill the applicant or future building decorum store or handle hararduus material
as dc0 d by the Cupertino Municipal Code.Chapter 9.12,and the Hcalth and Safcty
ode.Semon 25532(.)? f All roofs shall be inspected prior to any roofing material being installed.
O Yes No
Will the apphnnt prldterc building occupant tau cyuipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i,hara.dous air coounno.msµJefiood by the Bay Arca Air Quality Management all new materials for inspection.
I Disvlm7
0 Yea
1 have sad Ne tumaNnus materials reyvirethe s under Chapter 6.95 of the Cal do,
Iia Heal th S Safety Code,Socum 25515,23533 and 25534.I understand that if de Wilding
Jces n ,emrcntty haw a tenant Not it is my responsibility in nnuly We occupant of the
rcydi mcntxwhichmustWmnpriarwissuvmedraCceufepa aeu ey.� Signature of Applicant Date
owneeo mufiiedagent (/ ate All roof coverings to be Class "B" or better