04050036CITY OF CUPERTINO
-CONTRACTOR.TNF�ORMATIdN `,
BUILDING DIVISION PERMIT
BUIL DING ADDRESS:
99 LA RODA DR
JAHAN CONSTRUCTION
PERMIT 7.4050036
ERS NAME:
PERMIT ISSUE DATE
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SANITARY NO. CONTROL NO.
(408)782-3102
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under p of Chapter 9 (commencing
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ADD 35 SQ.FT. (KITCHE T ),
Dare " Contractor
CHITECI'SDECLARA N
1 understand my plana shall E used es public nerds
DEC �- 2004
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from Oc Contractor's License Low for the
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following reason. Permian 7031.5,Business and Professions Code: Any city or county
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which requires Permit construe, improv,, demolish, or repair any structure
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Sq. F[. Floor Area
Valuation
aalwupplicant
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poor to its issuance,also requires mmapplicant the forsuch Law (Chapter 9
that
ni Professions Code) it
me cingwitpSectioO")pmvisinmmfthe the Business ode)
(commencing with Section o(Division J theeged exempton.
add the Any vialail
Out he is exempt therefrom and the basis for the alleged exemption. Any vialatinn of
3 GAIN Nibidbef) 0
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($50B.
1, as owner of the property, or my employees with wages a their sale compensation,
will do the work, and the swcture is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Precisions Code: The Contractor's License Law dors not apply to an owner of
prepeny who builds or improves Neman.and who does such work himselforthrough his
own employees, provided that such improvements are not intended aroRered for sale. If,
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contacting with licensed communities to
cmutmet the project sec. 7044, Business and Professions Code:) The Cantracmr's Li.
'
cense law does not apply to an owner of progeny who builds or improves daemon, and
who contracts for such pmjecu with a contactors) licensed pursuant to the Conuactor's
License Law.
❑l amexemptunder See .B&PCfar Nisressnn
er Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of to fallowing dulamtimuh
have and will maintain a Cenifcale of Consent to self -insure for Worker's Compere
sation, as provided for by Section 3700 of the labor Code, for Ne performance of the
work for which his Permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of the labor Code, for the performance of the work for which this pens it is issued.
My Workers Comp nsation surxtcc copier and Policy number are:
Cartier. �j Policy No.:
C RTIFI A OF EXEMPTION FR WORKER
COMPENSATION IN NCE
(This section need not becompleted ifihe Permit is forma, hundred dollars(SIM)
or less.)
1 certify that in the performance of the work for which this permit is issued I shall not
employ any Person in any manner so as to become subject a the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Ceni icate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby that mere is agency for the performance of
which sedget.construction0 7, Cing
me work fur which this permit is issued (Sec. JOY], Civ. C.7
Lender's Name
Lender's Address
1 certify mat I have read this application and shote that the above information is
correct. 1 agree to comply with all city and county ordinances and slam laws relating to
building con macdon, and hereby amhndre representatives of this city to enter upon the
show mentioned progeny, for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cup actino against
liabilities, judgmenls,costs and expenses which may in any way accrue against said City(2
in consequence of the granting of this permit
"
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -PO NT
Issued by: Date
SO RCEREGULATI 5.
Re -roofs
Type of Roof
ignat c ppliconucommuder ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant lir future building occupant stere or handle hazardous material
defined by the Calendar, Municipal Code. Chapter 9.12. and the Health and Safety
c, Section 25532(a)?
All roofs shall be inspected to an roofing material beim installed.
El Yea Na
prior
P P Y g g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =open( use equipment or devices which
I hazardous air contaminants as fined by the Bay Area Air Quality Management
all new materials for inspection.
n?
❑secs o
1 have mad the hmarinus materials rcquimencnts under Chapter 6.95 of the Cali for
isR.I. aSafety Code, Seeum¢25505.25533and25534. lumbers' lure run building
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does unicamerally have a tenant mal it is my rcapnmiM1ility to roti y the uxupant of dam
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mmcnewhich must IPdon,w rife Ccrdfcateo Occupan y
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Sign r ofApplican[� Date
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All roof coverings to be Class "B" or better
Ow
r rizcitigcnt Date
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