03080049 (2) - CITY OF CUPI:RTINO
-
BUI LBUILDING DIVISION O=uNTRAC,T��a. O
RMATION RO
DING
ADDRESS: PERMIT N00 3 0 8 0 0 4 9
14S7 LTNDY PT.
OWNER'S NAME: PERMIT ISSUE DATE
JANICE & FRED ''BOITANO 08/12/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: • BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC11
0' LICENSEDCONTRACTOR'S DECLARATION
w 1 hcrchy affirm that am licensed under previsions or Chapter 9(commencing Job Description
?< wilhgcction7 )of Division So fur Busines.end Pmressinns Codc. dmyliccnala
a Iicellron d 7eo3ti REPIPE
Lice Lic.Y/� '
F p Oeste Con a ar _
EE ARCI CTS DE
W 1 cmand my plain shell M used as ie rtcnrJa ,
°0�', Licensed Professional
5 OWNER-BUILDER DECLARATION
<F I hereby affirm that I am exempt from the Contractor's License Law lor'the
00 following reason.(Section 7031.5,Business and Prnfessions Code:Any city nr county
5: which requires a permit In construct,altar,improve,demolish,at repair any structure
.ti pdorin its issuance,also requires the applicant for such permit to File a signed statement
< that he is licensedpursmnt1.theprovisionofthe,Cmetracmr'sLicenselaw(Clark,9 Sq. Ft. Floor Area - Valuation -
cFC (commencing with Section 7")of Division 3ofdicBushwasand Professions Coast)or 35624003 . 00
Nat he is aempl Ihcrefrom and the buds for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more than five hundred calls.(S50B).
❑Lesowner ,Jia pmpeny, re is employees withwages r theirsole 0,14.8 udon,
will duthe work,and the structureis roti Licded ense
ow dosed ntapplyto 70,14.Business of - U$,
and Professions Code:The Contractor's Littnu Lew does not apply so an owner of 502 - FINAL CO1V Ci RGY
property who builds or improves themon,and who does such work himself or through his
own cmployms,pmvided that such improvements us not intended or offered for sale.If. 507 - FINAL PLUMBING
however,the building or improvement ie sold within one year of completion.the owner
builder will have she burden of proving that be did not Wild or improv for puryae of
sale.).
El 1,as owner of the progeny,am exclusively contracting with licensed contractors to
emosuuct the project(Sce.7044,Business and Pmfcasions Code:)The Contractor's Li.
cense Law does not apply to an owner of progeny who Wilds or improves themon,and
who contracts for such pmjccu with a contractor(s)licensed pursuant to the Comosatoh
License Law
El lam exempt under See. ,B At P C for this reason "
1,3,wl
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ore of the following declarations:
have and will maintain a cemirmad,of Conant to self-insure for Workers Carrico.
n,as provided for by Section 3700 of the Labor Code,for the performance of the
for which this permit is iuucd.
have end will moimain Workers Compensation Insunnccas rtyuireJ by Secliun or the labor Code,for the performance of the work for which this permit is issued.
Wm1mr's Compensalipa insomnia carrier adad'yolic num r=�M87-
cr. eai�7ld•-'111r� gYg W
CERTIFICATE OFEXEMPn OM WORKERS'
COMPENSATION INSURANCE J
(This aniw need not hecomplemd if the lcrmit is for one hundred dollars($I(It)
or less.) 11�(ts'p(W.y/VS,IIt//
I cenify that in the performance of the work for which this permit is iawed,1 shell not
employ any person in any manner sn as m hccomesubjectto the Workers'Compcnalion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
became subject 0 she Workeh Conpensmion pmartimm of she Lahr Code,you nun
.J Z forthwi in comply with such provision or this Mobil shall be deemed revoked.
Z O CON STRUCTION LENDING AGENCY
'rs I hereby affirm that there is a construction lending agency l or the performance of
C't the work for which this permit Is issued(5ce.3097,Civ.C.)
W Q Lender's Name
'Y Lender's Address
V I c&&me that 1 have read this application and sure that the shove infm fisting Is U
0 F corrccL I m comply with all city and county oNinencof and sue hews relating to
V abovengimmaconstruction.and hertbyectioriae pprrxnatisn of this oily to enter upon the
9L ebovmmcmion agree
to s ray for corm goad keepers.
gL )agree to overs indemnify end keep harmlcu the City of Cupertino against
FF-t fn li ti Iu"mants,cosu and cxpcnas whi hmay in any way cecina against said
City9, f �/�
Po ICANTe GERSTANDStANDr IL OMPLY WITH ALL NON-POINT Issued by: Dale
RE ATIONS.
Xe-roofs
urs of Applicant/Commalor t
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant Store ar handle hevardous material
as defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea W.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
dl hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
DIYIIicl7 `1'
❑Yes 7�-r.
I he
a NehmaNnus materials requirements under Chapter 6.95 ofthe Calibre
ria Fkal afar Ccdc.Sccdun 25505.255 425534.1 unM.tand that iftM building ,
d nil new a mnenk Nes it u rt ponlily m miry the axupant of the
u' an w hmuslbcm t nu' van ofaCcnifsa or Occup cy. Signature of Applicant Dale
wo aulherimd agent Doc
All roof coverings to be Class"B" or better