03110019 CITY OF CUPERTINO r CONTRA JOR INFORMATION
BUILDINGDrJ1s1oN PERMIT ,.. ,_ �i
BUILDING ADDRESS: - LYNDA MIGUEL PERMIT N%3110019
R'S NAME: PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITEC"PENGINEER: BUILDING PERMIT INFO
_ BLDG ELECT PLUMB MECH
L� (�
Oa LICENSED CONTRACTOR'S DECLARATION
2 u 51 hereby affirm that I am licensed under provisions of Chapter 9(commencing .lob Descrlptl Otf�'w,NA
���
m with Section
9Njadof Division Sof the Fesinessand Pruressiens Code,md my license is r ,YAla'
,� in fell fbmeandeffect. ADD 724 SQFT
jSQ.
FT
License Class Lic.N -
f
Zia Date Contractor MAY 2 6 2004
f5ai ARCHITECTS DECLARATION
1 understand my plans shall W used as public records p�/�
;Ota Licensed Professional BUILDING
g OWNER-BUILDER DECLARATION
<E I hereby affirm that 1 am exampt from the Contractor's License Law far he
HO following mason.(Section 91131.5,Business and Professions Code:Any city or county ..
k S� which requires a permit to construct,alter,improve,demolish,or repair any structure
yZY prior In its issuance,also requires the applicant for such permit to Glc a signed statement
' S< that he is licensed pursuua ir
nnthe provisions of the Conwwr's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
X (commencing with Section 7")of Division 3 of the Business and Professions Codc)or
y
that he is exempt thcmrrom and Be basis for the alleged exemption.Any violation of
Section 9031.5 by arty applicant for apeiait subjects the applicant o a civil penally of 3WQNH'dL"i0 Occupancy Type
not more Nan five hundred dollars($50(l).
❑1,v owner of lde property, re is employees with wags as (Sec.
compen.don,
will do the work,and e: she Cont is Contractor's
Lbdeura,La a do fs n t apply.9oan Business
and Professions Code:The Contractor's and
Law docs not apply m an owner of Required Inspections
property who buildsored that s thereon,andwho does such work oroffredNmugb his
own employees,uildin orI Improvuch ement
withineam no,ear dedof
completion,
for owner.
however.the building or improvementg sold within one year a(completion,Ne owner.
of
builder will have the burden of proving Nal he tlitl not build or improve for purpose of
salt.). .
❑1,as owner of the propeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cove Law docs not apply to an owner of property who builds or improves therton,and
who contracts for such projects with a conuacter(s)licensed pursuant to the Contractors
-.mace Law.
I am ex
D�
empt antler Sec. B&P C for this..on
avyvf ( ce 9 3p. t`
WORKER'S COMPENSATION DECLAR N
I hereby affum antler Penalty of perjury oro or the fallowing declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Worker's Compcn.
.tion,as provided for by Section 37W of the labor Code.for Ne peronewca a of the
work for which this permit is issued.
Q 1 have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the Labor Coda,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nissoction need not Mcampleted Fire Permit is forone hundred dollars(glOO)
or less)
1 certify Nal in the perfa en.ou of the work for which this permit B issued.I shall nm ,.
employ any person in any mmner so as to become subject to the Workeri Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ccniocnc of Exemption,you should .
become subject to the Worker's Compen.tOn provisions of the labor Code,you mosso
.JO foMwi in comply with such provisions Or this Permit shall be deemed revoked.
'Z " CONSTRUCTION LENDING AGENCY
(-r red. I hereby affirm that there is a construction ending agency for the perfurmance of -
Ri ► the work for which this permit is issued(Seo.3097,Civ.CA
U Q Lenticr'I Name
Z) Z Lender's Address
V Q certify that 1 have read this application and sum that dm above infatuation miming is _
0 U Wilding agree to c comply with all city and county aradws of and arae laws relating to
U Wildingconstruction,iopentl hereby mthonprposesenutivesa(Niscity to enter upon Ne -
W ahovc(We) gree to coy forinspectionan keep ha
Q.
(We)agree to ons,indemnify and kith harmless the City of accrue
against
UZ incense Judgments,
enupofhe costs and of this expenses which may inany way accrue againslsaid City
C) z in eonuquencc of the graining of this permit. '
^+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC GULA- . n :/WC;l
�� �� 30 O Re-roofs
S umofApphc anu a Date
BAZAR S MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum Wilding Occupant glom or handle baurdous material
ctiaed by the Cupertino Municipal Cods.Chapter 9.13,and the Health and Safety
.Section 25532(4)?
❑Yes fa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or roam building occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
toll hn'.odues air conwmi esi is as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
f-1 yea Divas
1 have read the h.ardous materials requirements under Chapter 6.95 of the Califor.
do Health&SafetyCON,Sections 355115,25533 and 35534.1 understand that if dm building
does not currendy have a mount.thin it harry responsibility to notily the Occupant of Nc
mgai me whiehmmxt or to of aCertificamofOccupancy, Signature of Applicant Date ,
Y' All roof coverings to be Class "B"or better
Owner. iniffi rise gent Dam