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BUILDING DIVISION PERMIT
'ZI CONTRACTOR INFORMATION
FCITY
DING ADDRESS:
PERMITNO103070159
44 KINGSBURY PL
ER's NAME:
PERMITISSUEDATE
FINHILL MORTON
11/13/2003
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 affirm that I amlicensedtheBu under provisions of 9 (commencing
on p
with Section ]IXX)) of Division 3 of the Business and Professions CoJc, and my license is
i 70 s Code.
in mumrceandeffect.
REVISION --IN HOUSE USE ONLY
Dann=eelaza uex
Date
NO NEW PERMIT ISSUED, ORIG.#03010060
7'S DEContractor
ARCHITECTS DECLARATION
I W
REVISION— -403060050/#03110007
understand my Plan: anml used az pan0e rapma
Licensed Professional
OWNER -BUILDER DECLARATION
I Mreby arfrm mat 1 am exempt room d¢ Cantraaor's License Law far the
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which require a Permit to consumer, alter, improve, demolish, or repair any structure
innor in its issuance. also requires the applicant for such permit to file a signed statement
that he is licensedpursuantmtheprovisionsoftheContractor'sLicensehw(Chapter9
Sq. FL Floor Area Valuation
(commencing with Section 701)(B of Division 3 of the Business and Professions Cottle) or
that W is exempt therefrom and the basis for me alleged eaemption. Any vialation of
$ 0
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of
not more tun five hundred dollars
APN Number
Occupancy Type
p y yp
(5500).
36230023.00
1-]I. as owner of the property, or my cmployeas with wages az their.mle compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7014, Business
and Professions Code: The Contractors License Law docs not apply to an owner of
Required Inspections
property who builds or improves hereon, and who does such work himself or through his
own employess, provided that such improvementsare not intended proffered forale. If.
however, the building or improvement is sold within one year of completion, the owner.
builder will have he burden of ponying that he did not Wild at improve for purpose of
ail
❑c1. m owner of the property, am exclusively contracting with licensrd contractors to
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construct the project (Sec. 7014, Business and Profcuions Code:) The Contractors Li.
cense law does not apply to an owner of property who Wilds or improves; thereon. and
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whocontracts for such ponjeeu with a cpnmelor(s) licensed pursuant m the Canuanoh
S
License law.
`�
❑lam exempt under See. B&PCfor this rtazon
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1L__ .tea Data 0 ri o3
WORKER'S COMPENSATION DECLARA
-IOyN
��T
I hereby affirm under penalty of perjury one of the follmy(8 dalaratimen
I nave and will maintain a Certificate of Cornanua self -insure for Worst campen-
Shona, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which tris permit is Council,
❑ I have and will maintain Workers Compensation Insennce, as required by Section
3700 of the labor Code. for he performance of he work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bebemplcmd if the permit is forane hundred dollars (5100)
or less.)
1 ai nify that in he performance Of the walk far which this permit is issued, l shall nut
employ any person in any manner so az to Wcome subject a the WorkeW COmPmuatUm
Laws of California. Data
Applicant
NOTICE TO APPLICANT. If, at making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Lebon Cade, you must
rOmhwl to comply with such Provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nett is a construction lending agency for the Performance of
the work for which this Permit is issued (sec. 3W7, CiC, C.)
Lender's Name
Lender's Addmss
1 certify, that 1 have read this is
tour and sure than the above information
city and
bonding I agree m comply with all city antl county ordinances this nate laws relating toa
ng
onand norimany aumorimrtoses. ices of this city mcnmr upon the
V _
ahovetme
idnovenmentioned
d property fur purposes.
expeartion
(We) agree to ave, indemnify and keep hamless the City of Cupertino against
IiaConses. judg est
ts.the costs and may in any way accrve against said City
sm
quenc CC of this
of thegranting of this Permit.
it,
A APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH
ALL NON -POINT
SOUR E RE'Uj - S.
Issued by: Dale
Q
Re -roofs
S rc f pp amu oavactor Da
fIAZARDOGS MATERIALS DISCLOSURE
Type of Roof
Will the applicant
.are,future building Occupant store or handle h uarduus material
defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
E 7s
.......n L.✓'v
Will he applicant or future building =upon[ use equipment or devices which
rardous air contaminants as defined by the Bay Arca Air Quality Management
(:1Yes
1 have mad he hararderesmatorisls requirements under Chapter R. 95 Of the Califon
nia Heath&Safely CU .Secuoms 9)5,25533and25530.1unk,=dhmi(mc Wilding
dors not euormaly ham a le ant, Valli, my responsibility m nouly tbe wcupm, of he
A— -)-7 h uWmn -on �ssuanm oh Ccnifca¢�'upanyy
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
all new materials for inspection. -
(/-G /
Signature of Applicant
Date
All roof coverings to be Class "B" or better