01120065 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
TMTMIGGS LANE LUIS A MARTINEZ PERMIT NO. 01120065
Oftffl,"bA' . MARTINEZ "3YtT413{ bT1
I HONE: SANITARY NO. CONTROL NO.
n m Z ARCHITECTIENGINEER: BUILDING PERMIT INFO
FOF BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
i Z m C I hetehy affirm that 1 am licensed under provisions of Chapter 9(commencing UPGRADE POWER PA} SCCIptlOn
�C with Section 7")of Division Sof the Businessnnd Professions Code.and my license
mmis in full farce and effect.
K 6 License Class Lic.A
:?'Q De¢ Contractor
I O t; ARCHITECT'S DECLARATION
as I understand my plans shall be used as public rccards
1 6 p OLicensed Profexsionol
OWNER-BUILDER DECLARATION
w=vi I hereby aRrm that 1 Am exempt from the Convector's License Law for the
C?< following....(Section 703 LS,Business and Professions Code:Any city or comay $250
E F O which requires a Permit to conxtrucl.alter,improve,demolish,or repair my structure
A. pnono its issuarca also requires the applicant far such Farrah to file a signed statement
']rG ft��t - -- - ------ ---- -- --- -
IhetbislicemedpursuanstotNnmvuimsoflhe Cony i&sLimnYUw(Chapler9
. , 3
(commencing with Section TID )of Division 3ofthe Business and Professima Cartel t` f t ' jiE 't.E. $f : CI Valuation
or Nat he is exempt therefrom and the basis for the alleged eiemption.Any violation
of Section 7031.5 by my applicant fora pedant subjects the applicant toe civil Penalty _
of not more than five hundred dolu¢(E50W). APP r Occupancy Type
01,m owner of the progeny,tar my employee with wages as their sole compensation. 304 — ROUGH ELECTRI AL
will do the work,and the structure is not intended or offered for sale(Sec:7000,' -
Baaincss and Professions code:The Contractor's License Law does not apply tom Pfired Inspections
owner of propeny Who builds or improves thereon,and who does so
or throwgh his awn employees,provided Nat such nnucanemenls arc wya.i
.bffereBfoi cera.IL however.the building or tmprovemem s.old wt one yeai.fit - I
ompleti for throf uilderwill have the burden of proving that he bnot build
ar k'
c'
imp f purpose of sale) 21
']1 a n,,.f the progeny,um exclusively conimcfng w tit I rations 1.
construct the Project(Sec 7044 Business and Professions Code) C ntacmu
License Law does not apply to an owner of property who builds or it r �.
` conmacts.for,such.projecu with.a.conuacmr(x)licensed purwan,.to a
.. .and.who ., . . _. ....._..... _._ . . _. -' __... _ _. ... ..... ..... _.._..._ ... _.. .__... .. _.
Contmcmea License Law. .
❑1 am exempt under Sec. 1 B&P C fonhis mason
< -_ Owner Dam '
t .
WORKER'S COMPENSATION DECLARATION
1 hereby M.under family of perjury one of the following deelarations:
❑ I ban and'will maintainA Cenifiew,of Consent to self-in ds, for Worker's
Compensation, as Provided for by Section 3700 of the Labor Code. for the
performance of the work for which this pedant is issued.
❑1 have and will maintain Workers Compensation Ynii ance,as required by Section
_ 3700'.(the Inbar Code,for the performance of the work for which this permit is
issued.My Worker's Compensation Insurance artier AM Policy number tare:
.. . - earner il_ t tl 'iPolcy N.: t t;:CERTIFICATION OF EXEMPTION FROM ,',, ,
COMPENSATION INSURANCE
' (Thu section need not be completed if the pedau,is for one hundred dollars
(EI W7 or less.) , ,
shallnbt`employhan in person m m m' .. .:v.: :.:: .• - -` ... .• .. '
11 y, peronce, f the work f pe s Issued'1
Y P Y 1 Workers'
Comicant. n Inwx of California.Data
r w t ran t
Applicant. - .
manner eco as to become subject
to the - _-, -_ - _ _ _. _ .. ....
NOTICE TO APP the Worker's
aRcrmnot this Cenins of of Exemption,de,you
t,
becomesubjectto the such pr Compensation provisionsoftheeeeed Code,you must
O Q forthwith komply with such provisi.ns or this permit shell be deemed revoked.
I.
- CONSTRUCTION LENDING AGENCY
1 hereby"Earn that there is commercial leading Agency for the performance
t��t of the w.himnr which this permit'is issued(Sec.3097,Cil C.
t
..Lender'"theme'•' .. -.. ...._ _._ _.
0..Q
P:Z Iander'.Addrsss,' _ -
V'Q 1 certify that 1 have mad this application cert aunt thanhe above infodatetion is
W-.F„t cones.I agree,o comply with ell city and county ordinances and state laws mining
0_U to building cunsuacrion,mdhercby maintain repmrentativa ofdas city,oenterupan
W the above-mentioned prepeny for inspection purposes.
y (We)Agree As save,indemnify and keep harmless the City of Cupenino eget.,,
.In liabilities,judgments,costs and expenses which may in any way accrue against.'.id
Q,ZCity in consequence of the granting of this pemdt. '
- APPLICANT UpIDERSTANDS AND WIUUCOMPLY'WITH ALL NON-POINT " !
., SOURCE REGULATIONS. Issued by: Date
Sign tune of Appl canbCb ra t r ',Data Re-roofs
- HAZARDOUS MATERIALS DISCLOSURE �p /t1 -� cy I
Will the pplic ni or flume building oaupa t tore or handl hexardWs mamnel a of Roof J _. -- -- - •-- --
es d fned by)h Cupen ro M m p I Code Ch pie 9.12,and Ih H bit cert Safety
Code,
ad ❑Yen 255J2(e) s, ❑N Fxq' Al�� Y f ) a F -,. i tt.Y+
All roofs shall be mspeeted-prior to.any roofing material being installed,
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection',-I agree to'remove
not hvisdous Air cnnuminam,as defined by the Bay Area Air Quality Management
3isv;cl7 all new materials for inspection. Applicant understands and will comply with
(\`
El Y, , .❑N. all non-point source regulations: ;,,., ,
>� I have ta.afthe houadoua materials Iequiliments under Chapter 6.95 of the -
Colifornia HeahB&Safety Code,Smions 25505:25533 and 25534.1 understand that
If the building does not currently have a Ammar.that it is my respdnsibility to notify,he
.i4upam of rhe requlrelden s which must be mer prior,o issuance Ali Cerd illi of
Signature of Applicant Date _
Owners.AlWnaad Agent Data All roof coverings to be Class"B"or better
r:,.,„ , ,,.:.• �,q,;... ,. .. ' ' :'..-. r,- : .....:. ..4 .. ... OFFICE ..