02100107 CITY OF CUPER•11NOi
RUtI,DING DIVISION � PERMIT 'CONTRACTOR INFORMATION s`,
"W12)D't3n4ta NORTHCOVE SQ PERMITN02100107
GWTHA9 Wk ESS JOHN E AND MIRIAM S APPLICATITVY1n4TY2OO2
IONS: SANITARY NO.!! CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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�0G LICENSED CONTRACTOR'S DECLARATIONyp �j
w� thereby antrm rmlam licensed ender promndo.of Charles 9(commencing SUB-PANEL REPLINHR91T?On
�7wwith Section 7a)[1)as Division 3 int he Buss nesse and Promaxorns Code,and my licenu is �B� del ® �®
u in l ullonmenndeBea sex /�L
,E;Rt Licome Class Lic.N
== Date Q'SDDECLARATION
'
ARCIIITELTMAR 2 0 2003
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d < I understand my plana ahall be used as public records
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30 Licensed l'rnlcaaionul �� �����
'2y` OWNER-BUILDER DECLARATIONTheCommerce's
m <I 1 hereby ellirm roe 1 am exempt from The Convenor's License Law for the
�a 00 following reason,(Section 7031.5,Business and Professions Craft:Any city na county
I
$�+ which requires a remain in consumer,slur,improve,demolish,or repair any struaute
Foy pdnrm its issuance.also refoims the applicant fm such Permiuo file asigrcdssat am
Ho that he is licensed pursuant to the provisional of the Contractor's License�JwlChaper9 3*6Fh1IPIIEn9A@9 Valuation
SFO (commencing with Section 7000)of Division 3 of the Business and Pmfenions Cade)or
y $ that he is exempt Therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the appliemt to acivil penalty of i JAPM N Occupancy e
not more than Eve hundred dollars(sso(). 304 - ROUGH ELECTRICAL
p yTyp
❑1,as owner of the property,or my employees wit wager as Their sole compensation.
will do the work,and she samothe is not intended or offered for sale(Sec.7044,Business 585 Fllikl]
and Professions Code:The Conlmctar's License Law does not apply to an owner of egwre nspecttons
properly who builds or improves thereon.and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale,If,
however,use building or improvement is sold worth one year of completion,be owner-
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
1,as owner of the proper,am exclusively contracting with licensed contractors to
I, onion to project(Sec.70N4.Business and Professions Cale:)The Contractor's Li.
cords,Law doer not apply to an owner or pmpeny who builds or hardens Inc.,,.,oaf
who contracts far such proms acontramor(s)licensed puwuanuo Ne Contractor's
License Law.
Iam exempt under B&P C fart is rex a
Dain
WOR : S MPENSATION D AR Ti�N
I hereby alarm under penalty at perjury ooe of the following dccluations:
❑Than and will maintain a Cenifinu of Consensus to self-insure for Workers Cum peso
aatio s.u provided for by Section 3700 of Ne labor Code,for to peAormance of she
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37(1(1 of Ne Labor Code,for be Performance of tM work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This auction need not he completed if the perm.Is rnrone hundred dollars(.$Ilk))
,it to.,.)
1 ced IY that in theiWorker
f the work for which this Tourism named,1 skull nos
employray,wmwsto cnmraubicTt tee Woracur Cnmpemudnn
Laws of CaliRan —/ �/CC
Apnt ..ff 11�—
NOT I hero subjca m um be,nation provisions M the Ichor Coda,you mus,
OO forthwith comply with such provisions or this permit shall be deemed mvnked.
z CONSTRUCTION LENDING AGENCY
[-� h I hereby affirm that here is a construction lending agency for the Performance nl
Sex the work for which this permit is issued(Sec.31N1,Co,C.)
W� 0 Lender's Name
a z Larder's Address
V Q 1 certify Nat 1 hart read this application and sum that the above information is
(•'
come,.I agree to comply with all city and county ordinances and sate laws relating to
�U building construction.and hereby morrow,mpmmnmtivea of this city to enter spun the
til above mentioned property for inspection purposes.
(We)agree ,,...indemnify and keep harmless the City of Cupertino against
rNliabiLook judgments,costs and casinses which may in any way Secure against said City
U 7 in consequence of the grammin i ugof this Fer
•7 APPLICA UNDf:f TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCC GU ONS. '
(/ IN D A_ �Q -rOGfS
5'Iynatu p(fricmaCommour P c
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant nr Ionone building occupant stere or handle mora ores material
as defined by Ibe Cupcnino Municipal Code.Chapter 9.12,and the health and Safety
cede.seetien zss321a)' All roofs shall be inspected prior to any rooting material being installed.
❑Yes 10No
Will the applicant or future building acupant use equipmentnr devices which If a roof is installed without first obtaining an inspection,I agree to remove
omit kava dins air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
D'a..ut!
❑Yes Zan
I have mad re hvandous materials nequimmena under Chapter 6.95 of the Calificr-
nia Health Sufmy Cudc,Saxons 155115,25333and 25511.1 undeoanJ rani(rc building
I
not croons an nano.that it is my mspmeihiliry to boat Ibe rccupant of the
r ritem mwictinr met prior orinuenceofaCardficateus erp cy. iignatureofApplicant Date
ld
OwnerI authorized agent ate All roof coverings to be Class "B" or better