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BUILDING DIVISION I'I RMIT CONTRACTOR INFORMATION
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LDING A DDRESS: MOCELIN CONSTRUCTION PERMIT N00 4 0 4 0 113
866 LINDA VTRTA DR
NAME: PERMIT ISSUE DATE
IDIT & BARNCH DEUTSCH 1537 ORILLIA CTQ4/19/2004
E: SANITARY NO. CONTROL NO.
(408) 732-6655
ARCHITEC IENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30p
LICENSED I am ba sed od, ,,ov,DECLARATION
hap Job Description
�F I hereby affirm that 1 am littnud un��Jerppmvisiuns nr Chapter 9(commencing p
n� wish Sc lion] qaf Division 3af NC BusitAaalnd Prufcssinm CnJc,and myliccnac is
_per in full fir ea. ✓/ p FIRE DAMAGE REPAIR
p Z Llcen ass Lic.0
n F p Dmc Corer
¢¢wj AR HITECTS DQCIARATwil Pi
�2U tlersmnJ yplaas shall Mused ae publienec ods
g o U; Licensed Professional
g S OWNER-BUILDER DECLARATION
9 a S 1 hereby affirm that 1 am exempt from The Contractor's Liccrosc Low for the
p a following reason.(Section 703 15,Business and Pmressians Code:Any city or county
1 m 6� which requires a Permit to construct,alter,improve,demolish.or repair any simaure $11300
Zo' prior to its issuance,also requires The applicant for such Permit to file a signed statement
x < that he is licensed pursuant to the provisions(if the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
�p (commencing with Section 7")of Division 3 of The Bminess and Profusions Cone)or
y Nal he is exempt therefrom and Nc base for The alleged exemption.Any violation of
Section 7031.5 by any applicant for a perch subjects The applicant to a civil Penalty of4n0A'Ber00 Occupancy Type
not mom than five hundred dollars(S500).
Pane Y YP
❑Lasowner ,and
pmperty, re DIYemntendes withwage ssale(sole compensation, t "`
will Pr Newark.end the he Cmc is nm.License
proffered Lawdo for of apply to an Business i'
and Property
Wh build.
Code:The Contraaon,License Law docs not apply lf an owner of R qUl red Ip SpeCII ns
property who builds ar improveschthercon,toren and who does such work or offerOr ed
own employee,provided that suchimprovementsin not immndetlorleered for sale.If. -
builder ,wthe ill
the burden
improvement issaldediinot one Wild or cn proveion.theownco-
builder will have the burden of proving NeT he did not Wild lir improve for purpose of w s
sale.).
❑1,as owner of the propdny,am exclusively contracting with liecased contractors to
...tract the project(Sec.7044,Basin.and Professions Cotler)The Contractor's Li. .
ecce law does not apply To an owner of property who Wilds or improves Hereon,and
who contracts for such projects with a cormoor(Q licensed pursuant to the Contractor's `
Law.
WO
on ,B&PCfnr thi
Data
ENSATION DECLARATION
k{ 1f perjury ane of the following declarations:
Ihavof Consent to self-insum for Worker's Cumpem
Saturn,as provided for by Section 3]W of Ne Labor Code,for the perfam once of The
work far which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurer,e,as required by Section
37M of NC Labor Code,for the performanec or the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(This section need not hecompleted If The permiT is for one hundmd dollars($]N)I
or last
1 ccnify Na in the rformancc of N B vhich it is issuctl,l shell not
employs person aannerm T a so I 'to tl rrkers'Compensation
Laws ofC nue.
App''cant
N can TO APPLICA1Itt[[11'' er aking T nifcem of Exemption,you should
bec uhjca m Ne 'ri 'a Camp�paation provisions of Ne Lehnr Cndc,you muu
.Jz Ido comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a constmction lending agency lin the performance of
the work workfor which his permit is issued(Set,309],Civ.C.)
W Lender's Name
L4 Lender's Add.
az
U C 1 ccnify that 1 have reed this application and sum Ne(be above information is
ty E+ correct.1 agree to comply with all city and county ordinances and stale laws relating to
0U buildingcrnswnion,and hereby authorim representatives of this city to enter upon The
W above-me judgments,
property for inspection purpowhich es
may
Q. (We)agree to save,indemnify end keep humless the Ci Ty or Cupertino against s,
y estimate;pa which may in any way scenic against mid Ciry l(//
Uz inconsequNT of Degrantingof Nis Per mit.
APPL NT UNDER T NOS AND WILL COMPLY WITH ALL NON GENT Issued by: Date
SOUR G ATI
Re-roofs
Si m f pr' an etc
HAZ US MATERIALSDISCLOSURe �i Type of Roof
Will oficarour nrciam",ng uccupem smrc or handl ous mewrial
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
nJc, C]Yes
All roofs shall be inspected prior to any roofing material being installed.
❑YcsNa\
t / Will the applicant or fumm building occupant aseequipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
lit haeardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
trmt,
p Yes �M
I have reel the hanNnuus materials requirements unJer Chapwr6.95 of the Capron
Sa Sarey Coba,Secduas 25505,25533 and 25534.1 underamnd Nu trot,building
nes not all have want.Nat iT a my resp mihility w nodfy Ih Occup T of The
uirem cm wh'hen Tbe et 'orwissuance ofa Cctdgcaw of cup.
64 Sin u c o rat Date
Gwncr en Date All roof coverings to be Class "B" or better