05030220 CITY OF CUPEW171NO ^''"_*^ ."� �.R �" Ti
BUILDING DIVISION PERMIT GONTRAGTORINFORMATION -
, 4, N:x >
BUILDING ADDRESS: PERMIT NO.
TIMBERLINE BUILDERS INC 05030220
4 77 1 PL
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY O OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ft a,
LICENSED CONTRACTOR'S DECLARATION Job Description
C I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing .
w on Sectiion7")of Division 3 of me Business will Profession Code,and my licenscu
_Oh in full forteand effect. R. (� 3ZC J ((�
D v�? License Cl /' Lk.• REVISION--IN HOUSE USE ONLY
�—c Dam os TSDEcCr NO NEW PERMIT ISSUED/ORIG. #02080071
',' ARCHITECTS DECLARATION .�•
W� I undcrsund my plans shall Musdas public records REVISION #03090096
3
0 Licensed Pmferiinnal
s'05 OWNER-BUILDER DECLARATION
' Y I herchy affirm that I Mn exempt from the Conlrommen License Law for the w�
O O following reason.(Section](D L3,Business and Professions Code:Any city or county J
,,$V which requires a permit m corrosion"alter.improve,demobh,or repair any stmeture
poor to its issuance.also Inquires me applicant for such permit to file a signed summent
rz<' that he is licensed pursuant o the pmvisions of the Contocwr's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
'Fm (commencing wi th Section 7003)of Division 3 of the Business and Professions COME or
y Not he is exempt Mcmfmm and me basis for tee alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit subjects the applicam to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollar
❑1,u owner k.the pmpmy,rn my employecs wire wages ol nk,(Solt compensation,
will do the tions and Corm: sh Core ancone sande on,Law
reons Out a Sec.90a4,Business 3 5 6 2 4 0 0 4 . 0 0 Required Ins ections
and property
wh Predications Code:The Connectors nd who Law docs art apply lf an owner is q p
propertywhobuilds orimprovesthereon,endwho dessuch workhimself edthrough his
Man employees.provided malsuch imprmementsarcnot Tendedmplcmed Intrinsic. .
huilder .Ne building orimprovement
provinishathewithin ot ildear ormprovefrmeowner-
side.)
builder will have the burden of proving mu he did not beiltl or improve far purpose of
sak.l.
❑I,at owner of the pmpcny,am exclusively contracting with licensed contractors m
construct the project(Sec.7814.Business and professions Cade:)The Contractor's Li.
cense law docs not apply in in owner of property who builds or improves dmrton,and.
who contracts for such projects with a conoactor(s)licensed pursuant in the Comrades
License taw.
I am exempt under Sec. ,B&P C for this reason
OwnerData
WORKER'S COMPENSATION DECLARATION
thereby affirm under perulty of perjury ane of dm following dedvetion:
NOW1 haveandwillmaintaina Ce rinmof Consentmxlf-imumfe Wor eSCompen-
sation,as provided for by Section 3700 of the labor Code,for the pcolormasmc of me
work for which this permit is intend.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of me Labor Code,for the performance of the work for which this pemrit is issued.
My Worker's Compensation Insurance canter and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
(Thu meocn need not N completed HIM permit is forone hundred dollars(5100)
or kss)
I eerily Nat in me performance of the work for which this permit is issued.l shall Or
employ any person in any manns
marine sp gsaLbc9rynywaubmt110 me WmImia Compeation
Laws o'Cal r 0,CalfDte Y,diy
Applies., /Y•MX [rr 1.L
NOTICE TO APPLICANT.IL after making this Cenificam of Exemption,you should
become subject in the Worker's Compmasedon provisions of the Iabnr Cade,you mum
.,O forthwith comply with such provisions or this permit shall be deemed mvnkcd.
Z` CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that mere is a construction lending agency lm the performance of
fY the work fur which this permit Is issued(Sec.3097,Civ.C.)
W� A tender's Name
z lender's Address
fJ O 1 maify that 1 have read this application and Sum that the above ofmmuion is
U,f" correct.I agree m comply with all city and county ordinances and sum laws relating b
O V building construction,and hereby authrrirereprcmnutizes ofthis city to sinter upon the
abovementioned property for inspection purposes.
(~O. (We)agree to save,indemnify and keep homeless the City of Cupertino against
fq
liabilities,judgment,costs and expenses which may in anyway accrue against aid city
U Z', in consequence of me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Sigratum o(ApplicaO Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me applicant nor mfeat building Occupant tom or handle haeardand Safety
u d.,See by the 3, )?nn Municipal Coda Chapter 9.12,and Ue Health and Safety
code,Section 25533(a)?
❑Yes 951N. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildingOccupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnus air contaminants as dcfmCd by me Bay Arta Air Quality Management all new materials for inspection.
Diann?
❑Yes Wt r' /
Ihavc rtaJ me haaaNes mauoals rtyuimmenu under Chapmr6.95 of the Califro- �J/� or ✓ —
niaHealm&SafetyCade,Scfi.l5M,25533and MS34.1unde..dthaifthc building
does not cmren0y hove a.,nam,that it is my rnsprnsihility or notify the twcupant nr me
reyuirtmcn hhi-ehmustbeMCIp'arEdissuanceofaccrtifcaworOcmpna. Signature ofApplicant Dale
All roof coverings to be Class "B" or better
Owner or authomcd agent Dao: