03030123 CITY OF CUPERTINO �•'
BUILDING DIVISION PERMIT , O�N�C'Rrs.CTORTN"U�iMATION
BUILDING ADDRESS: PERMIT N0.
GEORGE MCCUTCHEON
OWNEz9 (DITI.TE AVE
R'S NAME: 21675 OLIVE AVE PERMITISS A
NE: - - SANITARY 2 4,12 NO, ONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMITINFO
.- BLDG ELECT PLUMB MECH
O
li00 LICENSED CONTRACTOR'S DECLARATION - Job Description
1 hereby effimt Thal 1 am Ilanwd under pmvisions of Chapmr 9(commencing CII eP
i
wlih Sncdon 7010)of Division 3 of Ne Business and Profession,Cnde,and my Iicenea is rINALED
= in full f...nd cffmn.
License Class uc.0 SERVICE UPGRADE
Dam Contractor -
e ARCHITECTS DECLARATION AUG 21 2003
y I undenlad nmy plawa.hall be dead public records
LkeneadPmfeuionat BUILDING
OWNER-BUILDER DECLARATION
i hereby effortNet I am exempt from tiro Cantranor's License Lew far Me
0 o following mason.(Section 70313.Business and Profession Code:Any city or county
$ which acquires a pnmit to constsuci,altar,Improve,dcmnliah,or repair any nmctuse
�S^ poor to its issuance,also requires be applicant for such permit to rile a signedstatement
e that he Is licensed pursuant to the provisions of the Conlncons License Law(Chapter 9 _ Sq.FL Floor Area 121k atlon
(cammcndng with Section]OW)of Division 3 of the Busi.... d ProfcsalmACnae),m 4 L v v
$ that he Is exempt Ihemfrom and 0m basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fore Permit subjects the applicant to a civil Knotty of
oaw c than R.e hunarcd dollar(S5Bo). Occupancy Type
at
01,uowner of the Pmpeny,wmy employes with wgcauthelr ole compcnution,
will do Ne work,and the structure is notimended mortared fonals,(Sm.70U,Business 304 — ROUGH b' 9Femfii1P& �
and Professions Code:The Contractor.Liame Law does Out apply m an=am of 1�vwqurrBO irlBgvu�a+v+nS
property who builds or improvesthercogand who doessuch work himealforthrough his 501 - FINAL ELECTRICAL ENERGY
own employees,pmvlded that such Improvementsue notimmnded conflicted fouls.if, SOS — FINAL ELECTRICAL
however,the building or Improvement Is mid within one you of completion,the owner-
builder will have the burden of proving that he did not Wild or Improve for purpose of
mI.J.
❑1,as Owner of tiro property,am exclusively contracting with Iianead contractors to
comtruct the Project(Sec.7044,Business and Professions Cade:)The Controm is U.
and law dors not apply to an owner of progeny who Wilda or improvv Merton,and
who contracts for such projects with a commeor(s)licensed pursuant to the ContnctOr. -
kertea Law.
1 am cacm under Sec. B& C for Thi.reason '
own
NORKER//', COMPENSATION DECLARE ON
e Ihereby am on& usury of perjury one of the fallowing declarations: . ,
hove and will maintain aCeniOcate ofCorrmattu self-insure for Waited Compen
nn,
As provided for by Section 3700 of the Labor Code,fm the performance of the
work for which Nis permit is issued.
❑I have and will maintain Workers Compensation Insurance,u required by Section
3700 of the Labor Code,for Ne pciformance of Ne work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number one:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secu...aed at W completed if the Permit is two=hundred dollen(glOB '
or less.)
1 certify that In the Performance of the work for which thus permit Is issued,I mall not
employ any mm' any amerce so eXomesubjec teWorken'Compe tion "
Law'of Cal mia. —
ppl T
E TO AP ICA? If,altar making this Caning¢of Exemption,you should -
Lcomc auhJect Ne Wa er1 Compensation provision of[be Labor Coda,you must -
,J forthwith cnmpl Ilh much provisions at this permit shall W Occurred revoked.
OCONSTRUCTION LENDING AGENCY .. -
E•v IWmby.mere Nn Nem is e construction lending agency for the Performance or
the work fur which this parmit h benumb(Sec,309.CO.C.)
Q Len@rs No
�Z correct'.alpme t
U 0 1 aNfy Nu 1 have mW this application and sum that Ne above information b
it,0 I—' cuildin l ora m comply with all coy arta representatives
ordinances mask laws m r urma the O V buildingconstruction.Pro and hereby auNodu rcoses, wwfthis city menmr ulmn Ne
W .hove-(We)agree
1.ertysaw for inspection kms,ha.
1},.r (Wc)agreeto save,Indemnify and hap hay in An the Cityor mCupenst against
liabilitiU faA inconsequence ents.of
graLLand expenses which may In my way acme against mid City -
V inconsequenceof DERST NDS lith permit, -
APPLI NT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU 0.EGULATION . _'Xg
(� Re-roofs
gnuu f ppli ndLgZOr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
I the applicant or fmum Wilding occii s ntnorc or andle arasdow material
As dcR by tiro Coplanar,Municipal Cosec,Chapter 9.11,and the Health and Safety
Cboc,Section25532h.)?0
Y., .� All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hamadom air contamimnts As deMod h the Ba Area Air
r r od.nty Management all new materials for inspection.
strict? ,
❑Yesblo
I have mad Ne huamnusmemrielsmquimmems under Clupmr6.95 of the Califor-
niaHulth&SafeiyCodo.Sect=Z505,25533and25534.1 dernuWmuifUc Wilding
docs not c 0y he a ranant,thea It is my Mility onto
n 'y the aaupanI of dm
vimm which..be eypri um oaccrtifmatenolpa.ry, Signature of Applicant Date
Z4-d-5
owner drat rbcs em Data All roof coverings to be Class"B"or better