03110136 CITY OF CUPERTINO ,`„`
BUILDING DIVISION PERMIT 9CONTRACTQR�I,NF,ORMATION ,fi
BUILDING ADDRESS: PERMIT NO0 3 110 13 6
'0371 MIRA VISTA AV
0.7,11SNAME: PERMIT ISSUE DATE
AT & MENACHEM FEIN 11/21/2003
PHONE: SANITARY NO, CONTROL NO.
ARCHITECTPENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MMECH
I� I�
300 LICENSED CONTRACTOR'S DECLARATION
I harchy affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
v¢ with Section 711IXf. Division 3aftht Dust.and Prafamions Code.md my license is �� n
.on in full force and affect. ADD 571 SQ. FT
] Z License Claw Lic.a i
7 Dau Contracror 11•' / f ,
e ARCHITECTS DECLARATION f�
< 1 Professional my plain.hell he usedu public rtcnrJa - ` 1 t 1 I
Licensed Pmfcasinnel
OWNER-BUILDER DECLARATION U (r
<f I hereby.(Seto Nat 1 1, exempt from the Contractors Liccnx law for the �l 111
O� following meson.(Section]11313,Business and sae.tho of Cute:Any city ar aunty (j ' ,/1$125000
which require a Permit m cnmtruq slug improve,Jcmnlish,or repair any nrvcmm
iy prior to its issuance,alto requires Ne applicant forsuch Fermi)a rile a signed summenl
�< that he is licensed pursuant n the previsions of the Contractors License Law(Chapter 9 Sq. Fl. Floor Area alua[ion
(commencing with Section 7")of Division 3 of the Business and Professions Code)or
5 that he Is exempt therefrom and the basis for the alleged exmPtion.Any violation of
Section 70315 by any applicant for a Permit ubjeeu thc applicant to.civil Family ofor Occupancy Type
not mom than rim hundred dollen(5500). P Y YP
❑I,as owner of the property,or my employees with wages as their sole compensation.
will do the work and the structure is not intended or offered[oras].(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply m an owner of Required Inspections
property who builds or Improves thereon,and whodatuuch work himselrar through his
own employees,provided that such improwments rte not intended aroffem l for sale.If.
however,Ne building or improvement is sold within one year of completion.the owner.
builder will ban the burden of proving that he did not build or improve for purpose of
mi
n 1.as owner of the property,am exclusively contracting with licensed contractors to
comlrvct the pmjea(Sec.704x,Business and Protrusions Code)The Contractor's Lo-
cenx law docs not apply in an owner of property who builds or impmws thereon,and
who contracts for such projects with a conuoular(s)licensed pursuant o the Contngor's
License law.
1 am exempt under Sec. B h P C far this moon
I I au Ir�z��Gg �•
0 OMPENSATION DECLARATION
the arfirmunder enaltyofperjuryomofths�l�ing dalentions: 3J`
I haw and will maintain a Cenifrcare of Consent to self-hilum for Workers Compcn-
cation,as provided for by Section 3700 of the labor Code,for the performance or the
work for which this permit is smed.
❑1 low and will maintain Worker's Compensation Insurance.as reyuortd by Section
3700 of the Labor Cade,for du performinec of the work for which this permit is issued.
My Worker's Compensation Insurantt carrier and Policy number am:
Cartier, Polley NO: _
CERTIFICATE OF MEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thi.ar.d.n need not hecompleted if the permit is for one hundred dollen($ig))
or less)
1 comfy Not in the performance of the work for which this permit is issued.l shall nut
employ any permn in any mum,an as m become subject to the Wor sari Compemalion
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption,you should
become subject to the Worker's Compensation previsions or the labor Child,you must
'Q forthwi III Comply with such provisions or this Permit that:x tamed mvokcd.
Z0 CONSTRUCTION LENDING AGENCY
I hereby M.that Nen is a construction leading agency for Ne Performance of
Z.>-t the work fur which this permit is issued(Sec.3097,Co.CJ
yQ Under'.Nam. ——
= Z Lenders Address
U Q I certify Nat I have mail this application and sou that the be.Information la
P correct.I agree to comply with all city and county on insnces and shift laws muting so
DU building construction,and hereby autbord MPmsentatives of this city to enter upon the
EQ above-mentioned property for inspection purpose&
(Wc)agree m saw,indemnify sed rm
keep halethe ss City of Cupetlino against
f�A
liabilities.judgments.costs Ind expenses which may In any way accom against said City
U z in conxyuencc of the Bnnfing uhhis Permit
APPLICANT UNDERSTANDS ANDW L COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATIONS.
ilk' Re-roofs
Si 5pxum arAppricanU Dau
ROD MATERIALS DISCLOSURE Type of Roof
Will plicae-orfm building occupant nom or band),havardous material
as dermad by the Cupenlno nicipal Cade,ChaFur 9.11,and the Hcdth end safety
Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
' ❑Yes (PNu
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardous air contaminants M defined by the Bay Area Air Quality Management
District? all new materials for inspection.
❑Yes (p No -
I have mud du hzrsd as materiab requirements under Chapter 6.95 of the Califor.
nos Hralth h Safety Code,Secdmts 505,15533 and 25534,1 command that if Nc building
Jura not cunendy haw amom m It is my resperuinlity,N and ythe t now[or the
requirements which muse hemn
priou its aftroe
C, ,ar.f Occupancy. Si
m Dau; gnature of Applicant Date
ar
121 �- All roof coverings to be Class"B" or better
ail egc