04030006 CITY OF CUPERTINO
BUILDING DIVISIONPIrRMI'I' * CONTIttSC"ZOR INFORMATION
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BUILDING AODRESS: BRUCE D. NILO PERMITNO04030006
1035Q MALVERN CT
INNER S NAME: PERMIT ISSUE DATE
11 BRUCE D. NILO 04/19/2004
ONE: SANITARY NO, CONTROL NO,
ARCHITCCf/ENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300
LICENSED CONTRACTOR'SDECLARATION
nsCod Jobb ������
u I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section 7M))of Division Sof the Business and Professions Code.and my license is
_'oro imm�eClforce and erfea ADD 464 SQ. FT. /REMODEL
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License Class LiC.N
iN Da¢ Cm DELL
As shall usbo DECLARATION
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D U IundcrnanJmyplansahallbeoudrpublic acnrd+ �r - nrn
e o to Licensed Professional .wed a+f�1e,eev
E.3 OWNER-BUILDER DECLARATION ! p���r
f I masa +(Erre that I ore exmpe from the Cessions a License Law for Ibe \W`is>�0■■ �`V■
p o following reason,(Section 74171.5.Business end Profession Cade:Any city nr county
I'lei which requires a permit In construct,elle,improve,demolish,or repair any evucmrt O O O Q
y prior to its issuance,also requires the applicant forsuch permit to fileasignednate
that he is licensed pursuant to the provisions of the Continuous Liccnx Law
Oor Area Valuation
(commencing with Section 7”)or Division S of the B usincas and Professions C or that he 0 exempt therefrom and Ne basis for the alleged cxemptlon.Any viola of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pcnahy ofe Occupancy Type
not more then five hundred dollars($500). f�.
Wis owner of the property,n my mmploycas with wages AS their sole compensation, 11 cal g)g
will do she work,and Ne suture isnot intended proffered for sale(Sec.7044,Business
and Profusion Code:The Conuacmr's License law dues not apply u m r r Required Inspections
OwnenywhabuipWodmpmveslhimprevndwho Ooes+uch work himself or s 1L
pwncmployce0.prvidmdthauuchmn.andwhome nm inteMedw is.&
however.the building or improvement is old within one Sear of completion,
builder will hale the burden of proving that he did not Wild or improv(w purpose of
sale.).
Qvfss owner of the propcny,am exclusively contracting with licensed contractors to
Convect the project(Sec.7044.Business and Professions Code:)The Contractor's Li.
Term law dots not apply to an owner or property who Wild+or improves thereon,and �1 ,v
who compacts for such pmjecn with a eomachas)licensed pursuant to the Contractor'+ L 4441(.
License Law.
(Ell lam mum eC, ,B kPC(nr his
wnerst-
- Data
/ WORKER'S COMPENSATION ATIMATION
( l hereby affirm under penalty of perjury ow of the following decimations:
I hive and will maintain acendio¢of comm to self-insure for Worter's Coni
..tion,u provided for by Section 3700 of the Labor Code,For the performance of the
work for which this Permit is iuucd.
❑I have and will maintain Wwkmis Compmration Insurance.a required by genion
3700 of the labor code.far the pmRmmmec of the work for watch Nis permit is issued.
My Wo kee.Cmi nuns on Insuns.earn.and Policy number art:
Cartier: Policy NO: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thus Auction need not W compinN ifthe Permit B forone hundred dollars($10(0
or less.)
I ecnify that In the performance of the work for which Ibis permit is imucd.I shall not
mmploy any person in any manner u m m become subject to the Workers Compensation
Laws of California.Date
Ap,lionl
NOTICE TO APPLICANT:IL after making this CCnIBCale of Eaemplloo,you should
become subject to the Worker's Compensation provisions of the labor Chic,you mum
.JO forthwith comply with such ranwimm.or this Permit list]be deemed mwkcd.
'z'"' CONSTRUCTION LENDING AGENCY
N
t-s 1 hereby work
Net Vert itsed13091,Cing .) lm the Performance of
!Yi the work(or whish this permit is issued(Sc,.(Sec.7091,Civ.C.1
GQ LMName
.7 z LCndcr.r's Addreu
U p 1 cenify Thu I harm read this application and state that the above information is
gL F core,,l agree to comply with all city and county ordinances and sure laws misting to
pU building construction,and hereby authmbe repreuntativeS Or this city to enter upon the
U eh.w.mentimied property for impaction purposes.
(We)agree to a...indemnify and keep harmless the City of Cuperino against
vis fn liabilities,judgments.costs and expenses which may In any way accrue agaammid City
t„)7 in consequence of the granting of this Permit,
m� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ONP INT Issued by: Date
SOU TIONS.
4 M0 s, Re-roofs
Signature otApplicant/CHAZARDOr Dau
HAZARDOUS MATERIALS occup DISCLOSURE Type of Roof
Willy the pliant or furan building e,Chapter
orand the
hamtpn mammal /
As defined im the Cupertino Municipal Cede,LTapter 9.12,and Nc Health and Safety
adm.scion 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant or low 'aAll
Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It humorous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Diablo?
❑Yin+ i Nu
I have mad the hansdousmauraks requirements under Chapter 6.95 of Ne Caliar.
ria Hcallh @ Sofety Cade,Sections 25575.25533 end25534.I underamnd that if the building
does not currently have a tenant,that it is my responsibility to no the occupant of Nc
mqulremcm which must W mel PHOT to umance Ofa CCrficma Of OCCup Cy. Signature of Applicant Date
wner ori' agent Oase
All roof coverings to be Class "B" or better