04060152 CITY OF CUPERTINO CLT�jXBUILDING DIVISION PEINIT m ��"'''�"` - (�' �' ' ♦'�i� r�'
BUIiLDINGADDRESS: PRESTIGE BUILDERS FF5eMRN004060152
10815 PENINSULAR A1
OWNER'S NAME: PERMIT ISSUE DATE
Y MICHELL REYNOLDS
E: SANITARY NO. CONTROL NO.
-(408) 254-4227
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7MP)of Division 3 ofshc Business and Prof es ions endmylicenseis
mfullfnrceam or Cl., ��' /5 REMODEL FAM.RM TO MS BEDRM & BATHRM
5 n Z License CI Llc.p
n Date " Con"Ecs'
N
C u� ARCH; CI'S D1 C RAIH.)
�v z=Cd
planta Max •"•�
C Licensed Profcsaionel N
WNER-BUILDER LAR
I hercM1y of rim that I ore exempt f he Ne Commcmr's License Lew for the
S:0 o following reason.(SecWn 7031.5,Business and Professions Code:Any city or county
S:00
$9 which mqu;ru a permit to concoct,al¢g improw:,demolish,or repair any structure
m;se pdormiuisuantt,alWo UirenMapplisnlforsuch Permit rile a signed statement
��< nnn
thathc elicensed punuanitothepmvisionsofthe Cmttmctoh Liccn=Uw(ChapLer9 Sq.Ft.Floor Area Valuation
££ D
k $ (cat he
(commencing wish Section 7olnd of basis for
oftic alleged
and Professions Code)or
.. Net he is uempl sherefrom and dm buts far the illegcd cscmption.Any violation of
Section 7031.5 by any applicant for a permit subjects one applicant to a civil penally of cr)0 Occupancy Type
not mom than five hundred dollars
❑1,u owner of the property,m my employtta with wages u thebsole compenutlon,
will do the work,and thnswcture is not intended oro0ered forests(Sec.7W.Business
and Professiane Cade:The Contractors License Law dors not apply to an owner of Required Inspections
property who bu ilds or imprays thereon,end who d.,,.h work himself or through his
awn employees,provided Net such improvements are not intended oroRered for We.If.
however.the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Nat M did not Wild or improve for purpose of
eaic.).
C)1,at owner of the property,am exclusively contracting wish licensed contractor to
Concoct the project(Sec.7040.Business and Professions Code:)The ContruWri Li.
cense law docs not apply to an owner of property who Wilds or improves thereon,and
who contracts for each projects wide a contractor(s)licensed pursuant to the Contractor's
ILaw.
[D
Alun aempt under sec. ,B&PC for Nis moon aT
Owner Dale -
7301. WORKER'S COMPENSATION DECLARATION
1 hereby affmn under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compcm dp
1
n,u provided for by Section 37M of the labor Code.for the performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Warsaw,u required by Section
of NC labor Code,for the performance of Ne work for which this permit is issued.
Worker's CompenulionInsunnttcertierendPolicynuMr are:e. Polley No.: GD 'o ^"' 1 '
CERTIFICATE OF EKEMPI'ION FROM WOR RS
COMPENSATION INSURANCE
(This action need not M completed if the Permit Is far ono hundred dollars(SIM)
or lest.)
k
1 certify that in the performance of the work for which Otis permit is issued.I shall not
employ any Person in any manner so As to become subject to the Workers Compensation `
Laws of California.Data
Applidnl`ix. -
NOTICE TO APPLICANT:If,after making this Ccr ifcWt of Exemption,you should
become suhlaCt W,(II9 Workerb Compensation previsions of 1M Labor Code,you must
Z forthwith dnmPly' h Such provisions or this permiuhal;he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Ft 1Wroby.Mrm the,them is.concoction lending agency for Ne performance of
ai> Ne work for which this permit Is issued(Sec.3097,Civ.C.) :-
W Q Lender's Name
jz Lender's Address
U Q 1 cemfy that 1 have read this application and state that she above information is
IL, F conacL 1 agree to comply with all city and county ordinances and ataW laws relating W
0U building concoction.and hereby authanne representatives of this city to enter upon she
W above-mentioned property for iupection purposes.
gys
(WC).fpna.t..v Indcmmfy and kap harmless the City of Cupertino against
„y In Ilabllities,judgments, end expenses which May in any way assents,against Sold City
U z in consequence of ranting of I Pe it.
^' APPLICA R if RSTAN N J ILL COMPLY WITH ALL NON-POINT Issued by: Date r
Soil" f TIONS. / e��W,.��r
g.� � `ftEaCOOEs
Sign of Applicam/Comsat r Etc
HAZAR S ATERIALS DISCLOSURE Type of Roof
Will the applicant or future uilding Occupant store or handle havamou material
u dented by the Cupertino Mun cipal Code,Chapter 9.12,and tM Health and Safety
Idws
e,Section 25532(01 - All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant or future building Occupant use equipment or devices which If a roof 15 installed without first obtaining an inspection,I agree t0 remove
I haxerdnus air contamirtAPas u JCfncd by the Bey Arca Air Quality Management all new materials for inspection.
rice?
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I have mad hamamrms matcriais requirements under Chapter 6.95oftic Calif.,
NcalNgr See ode,5c ns NIS,23533 anJ25534.1 underaWnd thalif the Milling
not cu y have man tb t it is my responsibility W nodly d Occuput of Ne
uimm Inc tprior W issuance oft Certificate of Occupancy. Signature ofApplicant Date
eraraamodzedagen �/ Data All roof coverings to be Class"B"or better