04050093 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON#TRACTQR TNFbRMA.TTO Vs
BUILpINkDDRESS: _ DANGaS CONSTRUCTION PERMIT Ncb4'050093
VISTA RD
OWNER'S NAME: PERMIT t9EU0 DATE
DANNY W N14'12
E: SANITARY NO. CONTROL NO.
(408) 365-8615
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u O o LICENSED CONTRACTOR'S DECLARATION IOW Description
zC 1 hereby affirm that 1 am licmued under provisions of Chapter 9(commencing p
<U with Section lIXM))of Division Sof Nnme Business and ProfessiCede,and my license is
'cPn inmBfnreeandeffect. REVISION--IN HOUSE USE ONLY
S Z LmCmm Cmat Lie.#
"�� Dam Contractor NO NEW PERMIT ISSUED/ORIG. #04Q20108
Qq ARCHITECTS DECLARATION
2< I understand my plans shall housed ss public records
Licensed Professional
g OWNER-BUILDER DECLARATION
if I hereby affirm Not 1 am CaCmpl form the COMOsCO f3 License Law for the
O O following meson.(Section 7031.5,Business and Pmfeasiov Code:Any city or county
m$ff which requires a permit m construct.altar,improve,demolish,or repair any structure
prior mire issuance.also requires the applicant far such permit to file a signed statement
FFF C that N is licensed pursuant o the provisions of the Contractor's License lsw(Chapter 9 Sq.Ft. Floor Area Valua"000
Y $ (commencing with Section 7")of Division 3 of the Business and Porfossions Cole)or
.. that he is exempt thcmfmm and Ne basis for the alleged csmptlon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy T e
not more thanRvehundredddarrMIKE). 35702049 . 00 p y YP
❑1,as owner of the prep ay,or my cmv ploycwith wages as their sale compensation,
will do the work and theswnure is notintanded oroRered forsale(Sce.7W.Business
and Profession,Cade:The Contractor's License Law does oat apply in an owner of Required Inspections
property who builds or improves thereon,a nd who data s tach work himself or through his
own employees,provided Nat such improvements are not Intended oraRered forsale.If,
however.the building or improvement is said within one year of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sahJ.
❑I.ea owner of the property,am asclusively contracting with licensed cuntractms to \
construct the project(Sec.704,1,Business and Professions Code:)The ContncloYs Li-
cave law does not apply la an owner of property who builds or improves Hereon,and
whoconw far such projects with a eoneraetor(s)licensed pursuant W the Contractor's
Linen
❑1 emin under Se<. .B&P C for this mason
O at Dete
W K R'S COM .NSATION DECLARATION ,
(hereby.111not under penalty perjury one al Nc follnor cothro me, -
1 have and will maintain aCerifiate of Consent to.11bb gwf for WarkcrSCompen-
satian,as provided for by Section 37W of the Ichor Code,for the performance of the
work for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Secdon
3700 of the Labor Code,for the peRormance of the work for which this permit is issued.
My Worker:Camp e..mind Insurance carrier and Polity number On
Camey. Polity No.: _
CERTIFICATE OF EXEMFDON FROM WORKERS'
COMPENSATION INSURANCE
Thissectimr wed notbecompmun!if the pmol,isloronc hundmddoilan($100)
carless.)
1 certify Not in Ne perfnvnance of Ne work for which this Permit is issued,I shall not
employ any person in any mahmose,as m become subject to the Workers'Compouadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after seeking this Certificate of Exemption,you should
become subjcn to the Worker's Compensation previsions of the Later Code,you most
.Jz forthwith comply with such provisions or this Permit shall be deemed rewired.
Z O CONSTRUCTION LENDING AGENCY
I hcrebyalRrre that there is a covtrucdnn lendingagcney for Ne performance of
7s, tha work fur which this Permit is issued(Sec.3097,Cih,C.)
Da Q Lender's Who,
7 z (sender's Address,
U 0 I Certify that 1 Nva read this application and sum Nat Ne above infmmatiun is
La. correct.I agree to comply with all city and county on inarms and sum laws relating he
0 C.) building construction,and hereby authorise represenudvev of this city to enter upon the
W above-men0oned Property for i capcuan purposes.
gy (We)agree ro save,indemnify and keep Wheless the City of Cupenino against
y in
fthecosuandof this permit, may in any way accrue egainitsaid City
U z in conmgocnee of the Bmnlin6 a(Nis permit,
^� APPLICA NDERSTANDS A DN WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATIONS. /V///1/✓n��d
Re-roofs
signator LcanVCam ser
HAZ DOUS MATER( DISCLOSUR Type of Roof
Will Ibcapplicant future building rat stare or handle haw On material'
as defiwd by the Cupen' Monicipal Code,Chapmr 9.12.and the Health and Safety
oti dean zss3z(an All roofs shall be inspected prior to any roofing material being installed.
Yea Na
Will Nc applicant r for.
tod"ing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haysrdous air Commmiaanm as defined by the Bay Ana Air Quality Management all new materials for inspection.
District?
p YC9 b
I have mad the hmaNemouncrialsrcquiremenis under Chapmr6.95 ofthe Califor-
niaHcalth&Safety Cadc,Scctiov 5505,25533and25534.lun&mmndthalifthe building
does no c City aw a mnam, at it h my responsibility m lily the occupant Cf Ne
require chmustbcmet drmisstaanCOO(eCcnlfcate cupancg Signature of Applicant Date
owner manNon] gent `Date All roof coverings to be Class "B"or better