04050125i
CITY OF CUPERTINO
�^i
BUILDING DIVISION PERMIT
sWO }'fOL"�Y'g�g�gvi
'KEE
BUILDING ADDRESS:
MC TRACTOR SERVICE
PERMIT 1004050125
OWNER'S NAME:
PERMIT ISSUE DATE
CITY Fna
ONE:
SANITARY NO. CONTROL N0.
408 243-
ARCHITELT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
j0
LICENSEDCONTRACTOR'S DECLARATION
Job Descri tion
P
F
homey affuro Nat 1 am licensed under previsions of Chapter 9 (commencing
auj
with Se Lima 1000)of Division 3 of Ne Business and Professions Code, and my license is
e
mfull and arrea
DEMOLITION OF EXISTING MOBILE HOME
License Class Lic. X
nseCla
Date contracum
NO FEES FOR CITY PROJECT
E1
ARCHITECTS DECLARATION
Uy.
undennnd my plans shall k used u public meord.
?y
Licensed PNleaBlanBl
33
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am1. exempt from the Contractors License Law for the
p O
following mass.. ]113
soli Code: Any city or county
hers and ve.
da
conelmcL alter, improve, demolish, or repair any swemm
permit t ro et,
which requires permit
i<thu
its issuance, n
Oenle se Law(stateme.
pnormits nsed palso uantto ms The provisions of for the Contractor's License
he is liccnudpunuenlmthe pmvisiorts nfthe Co.ncmr's Liccnu low (Chapter
Sq. Ft. Floor Area
Valuation $0
'r$
3
(commencing with section 1") of Division 3 of the Business and Professions Code)or
that M is exempt therefrom and sire basis for 0m alleged eumpdon. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Pewit subjects the applicant to a civil penally of
not more than Bva hundred doll.. ($500).
❑ I, a owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the ,it. and Ne.wnura isnot Intended proffered foredo (Sec. 7044, Business
and Prefassioa Coda: The Conomm'a Ltceme Law docs no, apply to an owner of
property who bull da or i mp rpm thereon, and who does such work himself or through his
own employees, provided that such immintended proveents are not inded moffered for sale. If,
however. the building or improvement Is sold within one year of completion, Ik owner-
builder will have the burden of proving Na, he did not Wild or improve for pmpou of
W.J.
I, as owner of the preperty, am exclusively cmnlnnttng with licensed emoraclors to
c wn Ne project (Bee. ]004, Business and Prof.dans Code:) The Conmwmr's I.I.
-
cense law dors oat applyromOwner of property who Wilds or impmws Notion,and
O�\
who convects for such pmjec%with a ennead licensed pursuant m the Convenors
enu Law.
m erfia a Oe Sec. , B & P C for this recon
Ow' �-� Date �����
\
WOR ER'SCOMPENSATIONDE��CARRATION
1hembya(rrmunderpenaltyofperjuryane� ;Agowi.gdmlm.(tmn:
1 have and will maintains CertiRam of Consent to uir-mame for Worksr's Compen-
sation, u provided for by Section 3]00 of Ne Labor Code, fm to Performance of the
work for which this pemit is issued.
❑ I have and will maintain Worker's Compensation Insurance. as mi by Section
3]00 of the labor Code, for the performance of the work for which this pewit is issued.
My Workers Compensation Insurance artier and Policy numkr am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CDtisuctim need not becompletetl tribe Mmitis formic hundred dollen (SI00)
or Ices.)
I comfy that to the performance of the .,it for which this permit is issued, l shall nut
employ any person in any manner ani an become subject o tk Workers'Comp rtution
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Ccnifica a of Exemption, you should
become subject to the Worki Compensation provisions of No Labor Code. you must
t z
forthwith comply with such provisions or this permit shall to deemed revoked.
(^
- CONSTRUCTION LENDING AGENCY
r
hereby that there tssued(mc5innlending agency for the performance of
' r�
which
the work (ser which this Pewit is issued (Sm. 31)9'i, Civ. CJ
'
I Q
Lenti ms Name
Lenders Address
z
Q
1 cenify that 1 have rad this application and aim that the above Information is
F
corns 1 ague m comply with all city and county ordinances and sou laws relating to
jU
W
1
building convection, and hereby intones mpreunudves of this city to enter upon the
shave- (We) nedare to ertysave for impactionkeep purposes.
(We) agree to ave, indemnify kith hamlets the City or Cupertino agdnst
to against avid City
l�
rA
s Z
)'�
nt any way eccrve
incomecluc mofthe granting expemes witch may
log of thispermit,WILL
AP LIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
APIQLIICAcTcof UNDERSTANDS
Issued by: Dale
32O RC TIONS.
Jus ��
Re-roofs
Signamm of ApplicantoCsntranor Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII the applicant m future building occupant atom or handle hazardous material
as dcrincd by the Cupertino Municipal Code. charm 9.13, and the Health and Safety
Adlll�od..
Sectiones 25532(a)?
Nu
All roofs shall be inspected prior to any roofing material being installed.
❑Y
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant r rectum building occupant use eyutproent or devices which
mit h.vardous air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
Disuid? —/'
❑Yes prvu
1 have mad the haardousmaterialstmuirm cntsunderChapmr6.95ofthcCalifor-
M.Hc.lth X Sufcty Cmdc, Sections 25505.35533 and 25534.l mdersmnd da of the Wilding
does not cemn0y hoes a sone.. out it is my responsibility m notify the mcup.m of the
uyuiremcnts whit et primr.tasaanpe ora cenific mrOcapanP.
Signature of Applicant Date
M� 'S j�
"B"
All roof coverings to be Class or better
d
Owner or authorized agent Dam
CITY OF CUPERTINO <-
DEMO Vii:'
CUPE�INO PERMIT APPLICATION FORM
APN #
Date:
j
Building Address:
�7
C�
�/
!/
Owner's Name:
#:
Contractor:
c e #:
Contact:
Phone#:
Ap UContractor.
Buildin ermit )nfo:
Bld
lect
Plumb Mech
Job Des ' ion:
ential:
-
Co r i
Sq.Ft. Floor Area:
0
$/Sq.Ft.:'
Architect/Engineer:
Valuation:
Type of Construction:
Occupancy roup:
Qty.
Appl>eFee ID Fee Description Fee Group
BSEISMICOM
Seismic Residential
I - / /I BPI-ANCHK I Plan Check Fee I//r U" BUILIDNG I
BUSLIC I I Business License j —1 BUILIDNG