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CITY OF CUPERTINO
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, NTRACTOR INFORMATION.
BUILDING DIVISION PERMIT
,C
auawrvc ADDRESS:
:KIMBERLY PAGE
PERMIT N�00
41137
0465 ORANGE AV
OWNER'S NAME:
PERMIT ISSUE DATE
KIMBERLY PAGE
10/20/2004
NE:
SANITARY NO. CONTROL NO.
ARCI IITECnENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRd ARATION
Job Description
underSoEC
1 herchy affirm Thal I em licensed under provisions ofs Code. 9 (commencing
fCarr
with Section Sof the Businesand Professions Code. and my liccnm is
and effect,
amllmree arta errant.
ARCHITECTURAL FEAT U; gNAL ED
Liccnsc Class Lin tr
Date ConTS ractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public meads
NOV 2004
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Craft: Any city or county
which requires a permit to oansuucl, slien improve, demolish, or repair any suuctum$300
prior to Is latumm c, al.u) requires the applicant for such permit to File a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant n the provisions of the Comment's License Law (Chapter 9
(commencing with Section 7m)q of Division J of the Business and Professions Code) or
Nat he i, exempt therefrom and the basis for the alleged exemption. Any violation of
3bAaT4ffZTbeT0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects Oe applicant to a civil Penalty of
not more than raw hundred dollars (5500).
0 1, as owner of the property, or my employees with wages ax their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 70414, Business
and Professions Code: The Chairman's License Law does not apply to an owner or
property who builds or improves auction, and who does such work himself or through his
own employees, Provided Oat such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year or completion, the owner -
builder will have the burden of roving am he did not build or improve for purpose of
sale.).
0 1,4s owner of the property, am exclusively commcting with licensed convectors to
construct the pmjecl(Sec. 7044, Business and Professions Corle:)The ConUaztor's Li-
_
come Law does not apply to an owner of properly who Wild, or improve, thereon, entl
who contracts for such projects with a commmmN) licensed pursuant to the Contractors
-.
w nu Law.
am exempt d r Sec. . B & P C for this reason
Owner ate, _2/%—
WORKER'SCOMPENSATION DECLA ION
I herchy affirm under penalty of perjurylle-of the following declarations:
1 have and will maintain a Certificate of Consent a self -insane fur Workers Canaria'
lion, as provided for by Section 77W of the labor Code, for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance, as required by Section
3703 of the labor Cedn for the performance of the work for which this proof is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier: Policy N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This uctom mold not hci omplerm if the pmmil is faro. hundred dollars ($IN))
or loss.)
1 certify that in the performance of the work for which this Permit is issued, 1 shall not
employ any prawn in any manner srazit) become subject to the Workers'Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Ceniticate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that mere is a crosuumion lending agency far the Performance of
the work fur which this format is issued (Sec. XM, ON. C.)
Lender's Name
Lender's Address
I certify that 1 ban read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state law, relating m
building Conswnice. and hereby sumorim represcamoves of this city Io cr cr upon the
above-mcatihned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cos¢ entl expenses whicA may in any way acorea egainxl said Ciry
in consequent he gran of this Permit.
APPLICAN UN E N S AND WILL WITH ALL NON -POINT
Issued by: Date
C/ER GU AT 'D 2^ 6 �-
Re -roofs
Type of Roof
VCOMPLY
Signa c plica omraetor - D.m
HAZARDOUS MATERIALS DISCLOSURE
Will am applicant or future building Occupant store or handle hant ous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. section 25532(a)7
All roofs shall be inspected to any roofing material being installed..
�Ycs �Na ;
prior
'
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
strict? .,e'
O Yes S�No
Ihave MM Oc Immoh/ussraticials requirements under Chapter 6.95 ofthe Califon
,
ria Health &Safly ode, Senators 255(15.25577 and 25534. l undersund Outline building
Jws not curt try a nt, a it is my responsdolity m notify the nacupanwf the
m
oquiremcm.whi I 'rmissairmm-scenirearenraetopany.
Signature of Applicant Date
^
All roof coverings to be Class "B" or better
Dw
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