02100041 CITY OF CUPERTINO •' "^
BUILDING DIVISION PERMIT „CONTRACTORINFORMATION:
BUILUINGDAD E'S: �� „d PERMIT 2 /O O U G4/
7ARCHITECTIENGINEER:
ER'S NAME: '1I\J APPLICATION SUB DATE
ohn Chet-, 0 0 2ooZ
NE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB t MECH
LICENSEDCONtRd underSDECons(if hapON
1 hachy uffrm Nat 1 um IiccnscJ under pmvisicne of Chapter 9(commenting js hW��w�,e Fo yy�� )7 p Nyri tion
gacecu. tlfl(p FDivisinn3ofmc Dust nc pJPmf•scions Cod andmyliccnsc is W �/
in full fore a n ,
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Epw� ARCHITECTS,shtsomDsp r ION f
Ea' 1 unticrxlonJ my plana shell he uxeJ as public records /�
maw LicensedProfessionai "/ar��e 6�2 SCS • rT. JAN 2 8 2004
OWNER-BUILDER DECLARATION
aI 1 hereby affirm that 1 am exempt from the Contractor's License Law lin the
ce aO li,llnwing reason.(Section]1131.5.Business and Professions Cudc:Any city or comply BUILDING
'22 which requites a permit to construct,alter,Improve,demolish,or repair any stmmro
c
m v, prinnn is Lssuvnce,elsu myuiresthc applicvm[nr such pamBmfilcaslgneJ s,o,emen,
C < that he is licensed pursuant to(be provisions of the Cnmmcmrs Licenses Law(Chapter 9 Sq. Ft. Floor Area Valuation
'l-M (commencing with Section WXXE of Division 3 of the Business and Professions Code)or O o0D
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section](131.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy
not more than five hundred dollar,(S5(IB). ApN N c>37
P Y Type
❑1,as owner of the property,or my employees with wages IS their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.71144.Business
and Professions Cash:The Contractor's License Law docs not apply 10 an owner of Required Inspections
properly who huifis or improves thereon,and who does such work himselfor through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
L as owner of the property,am exclusively contracting with licensed contractors m
ns rucl the project(Sec.1044,Business and Professions Code:)The Contractor's Li- r
Li-
cense Law does not apply to an owner or property who builds or improves thereon,and
who contracts for such projects with a contractor(,)licensed pursuanuo the Competitor's
L'a sm Law.
I am exempt under Site .B&P C for hismaimen
�r rn a�krh D le I Ta V
/ WORKER'S OMPENSATION DECLARATI
I hereby affirm under penally of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Cousenno self-insure for Worker's Compen-
arrow.as provided for by Section 31110 of the Labor Code,for the pencoomma,of dies
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the portbrmance of me work for which this permit Is issued.
My Worker's Compensation Insurance carrier and Policy number aa:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. t"
Drie section n ed not he completed if the permit is for ones hundred dollars(SIM)
or less.)
1 certify that in,he performance of the work far which this permit is issued,1 shall not
employ any person in any manner so as to become subject o the Workurs'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cmnilicate of Exemption,you should
become subject to the Worker's Compensation provisions of the Lanor Code,you mus,
OO forthwith comply with such provisions or this permi t shall he deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
[-1 I hereby ollirm mal Nae is a construction leadi ag agency Ba the performance of r
E
F�-t the murk for which this permit is issued(Sec.3M7,Civ.CJ
aQ Lender's Name
.D z Lender's Address
U p 1 cmnify that I have read this application and mate mal the above information is
V. Pcorrect.I agree to comply with all city and county ordinances and state laws relating to
C)U building concoction,and hereby authorize representatives of mis city to enter upon the
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above mentioned property for dexpenses purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Uh
liabilities,fragments,of
costs andof this esmit. may in any way accnc against said City
(„)7 A PLIC NT of DERSTAN of this permit.
❑❑ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO R REGULATIONS.
644D)"
Re roofs
re of ApplicanUCnmmma &4,
HAZARDOUSMATE LSDISCLOSURE Type of Roof
Will the applicant ordome buil txcupam stem or handle hazardous material
n dented by the Cupertino Mmme Cotler Chepta 9.i2,and the Health and Safety
ace,Section zss3z(aY' All roofs shall be inspected prior to an roofing material being Installed.
❑Yea Na P P Y g $
Will thea applicant or future broil If a roof is installed without first obtainingan inspection,I agree to remove
pp g occupant use equipment or devices which P $
emit humphes air contaminams as coed by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have read the haatdous materials requircmems under ChapmrM1 95 of the Califtx-
nis Health Ar Safety Cade,Salmons 25505,25533 and 25534.1 understand thm if be,huilding
does no, ntly have a awarl,mm itis my responsibility,o notify me up.1 of me
mgmi Is which must m a mearacmnircamaI cop y. Signature of Applicant Date
own a ammariacd agent i te✓1. All roof coverings to be Class "B" or better