05050150 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CONTRA TQR,INFORMgATIQN , •
BUILDING ADDRESS: CAREY CONSTRUCITON PERMIT N005050150
18901 PENDERGAST AVE
OWNER'S NAME: PERMIT ISSUE DATE
LETICIA PRADA KING 1887 COAST
NE: SANITARY NO. CONTROL NO.
(408) 448-1079
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0Z, LICENSED CONTRACTOR'S DECLARATION O O O
m Job Description
IWmbyaffirmWt1smlicensedunderprovisionorchapter9(ammencing
Z with Section 7000)of Division 3 of We Business and Professions Code,and my license or
« imm�fwaandeffea ADD 384 ' -MASTER BEDRM/BATHRM
j tj= License Clues Lie.N
&fie Dae Contractor CONTRACTOR: CAREY CONSTRUCTION (06/09/05)
E'.J' ARCHITECTS DECLARATION
?W U 1 understand my plans shall he used as public records
a
D G H Licensed Professional
OWNER-BUILDER DECLARATION
<Z I knehy affirm that I am exempt from We Connaches Liecnw Law for the
00 following mason.(Section 7031.5,Business and Profc.son Code:Any city or county
K m which mqulres a permit to comawct.alter,impnw,demolish.or repair any swcture
LZi prior m its issuance,alw requires the applicant for web Permit to file a signed smement
< that he is licensed pursuanOo We previsions of the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area Valor tip�451
x�� (commencing with Sudan 7000)M Division 3 of Wo Business;and Profeaiom Coale)or
e 53.- that he is=wmpt thcmfmm and the basis for We alleged exemption.Any violation of
S=cdon 7031.5 by any,applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy
not mom Nan five hundred dollars($500). 37533030 . 00
p y Type
0 1,as owner of she property,w my employees with wages m theirwlc compensation,
will do tie work.and the swmum u nm s Livens Law does
he,a(Sec.to a, saner of
and Profusions builds
The wsthereon, ndwho dose don not apply lf an owner is Required Inspections
ow.
property who builds lid that
thumprove who dassuehw.rk himselfor tiuough his 811�4a/pppp
loweer.Weees,ping or i thin suchimprovemantsamne year fcmoRered for ower. n
howder.We building orimprovementissold within one year of improve for
Dwarf Asa
bander will n.a the WNcn of proving that W ata net Wild or improve r«paryose or
oath.).
0 1,as owner of the pnpcny,am exclusively contracting with licensed contractors to ���
Construct We project(Sec.7814.Business and Professions Code:)The Con memo's Li.
cense law does not apply to an owner of property who Wilds or improves thereon,and. 70ps
who contracts for web projects with a conu emr(s)licensed pursuant m ac
Ile Canmafs
License Law.
0 10m exempt under Sec. .B N:P C fm Nis mason
Owner Data
WORKER'S COMPENSATION DECLARATION UTP y b
1 hereby affirm under penalty of perjury one of We following dalaration:
0 1 have and will maintain aCeniGcate of Consenuo salt-insure for Wormes Compcm
cation,a provided for by Section 3700 of We lobar Code,for We performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance.to"Wood by Section
3700 of the labor Code.for the performance of th=work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is forone hundred dollars(SIM)
or less.)
I certify Nat in We performance of the work for which this permlit is issued.I shall not
employ any personina ma^� t��?ne ctn�l�Worlxn'Conpewtian
user Calif. �'L—z l7/� 1
Applicant A!! 'ir ���
NOTICE.�'O API Alift:1L after making this aero on,you should
ba0me l en b the Worker's Compensation previsions of the Labor Cock,you must
.J O f0Mm tr ply with such provisions or this Permit shall W deemed mwkcd.
zy CONSTRUCTION LENDING AGENCY
[—� I hereby alarm that Were is a construction lending agency for tW performance of
C the work for which this permit is issued(Sec.3097,Cih,C.)
Qlender's Name
D
z lender's Add.
U Q 1 cenify that I have read this application and some that We above information is -
D. F' eonecs so
I agree to comply with all city and county ordimnas and w laws totaling to
�U building cooswction,and hereby authorim representatives of Its city to enter upno the
yabove-mentioned prepony for inspection purposes
(We)agree to ave,indemnify and keep harmless the City of Cupar into against
h liabiliuu.)udgmcma,now and expenses which ma yin ywaymcraagaimtoid City
U,'Z in c0megancc arth grantiagor Nis permit.
^
AP LIC UN RSTANDS AND WIL C PLY�WITH ALL NON-POINT a,Issued by. Date
50 EG S e
6 �3 Re-roofs
Si cot ADDlinndCanuacmr Date
NAZARDOUSMATERIAISDISCLOSURE Type of Roof
Will the applicant or future Wilding occupant nom orhandle hvnrEous material
U defined by We Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cork,Station 25532(.)?
GYn ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmB harardnus air conomimnts a defined by We Bay Am.Air Quality Management all new materials for inspection.
District?
❑Yes ElNo
Ihnveread thehaumb maerials reyvimme under Chaplcr6.95ofIMCalifon
riaH.I"Safety Cada Scedom 233(15.25517 and 331.1 unikrslandlhuiflW Wilding
does nos 4rentubawee enantthatisism mibilitymnodlyft=upantnfthc
MV_p&
w c maatlrmetpd.r anncertireyworOca Signature of Applicant Date
U ( rt'/
thad'rcE+s=rot D,w All roof coverings to be Class"B"or better