04010119 CITY OF CUPERTINO X1.11vap 'lo, `4
BUILDING DIVISION PERMIT CONT=RACTOR INFORMATION
x,.?m _ rairavrar �.*;A & @lire „klPvTI,
BUILDING ADDRESS: J&M TERMITE CONTROL INC PERMIT ND04010119
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITELT/ENGINEER: - BUILDING PERMIT INFO -
! BLDG ELECT PLUMB MEC"
X00 LICENSED CONTRACTOR'S DECLARATION lob Description
with
w� I hereby Affirm<o. that I en licensed under previsions of Chapter 9(commencing p
�Y Section 7")of Division 3 ofthe Business;and Professions Cnde,aad my wan.is � \
In full fore rad fie
zgi License Cl ` LIqq�° TERMITE REPAIR-BATHROOM
ter c C' V /jam
ARCHRECTS A O
understand
O T undernd my plans shall W used AS public rtcnrds
A. Licensed Professional v //
OWNER-BUILDER DECLARATION VVV
�<f 1 hereby Affirm that I am exempt fare the Comms Coo License Law for the
i.O O following mama,permit
t Yin 1.5,Business and improve,
de nm Code:Any city s county
$a- which its issuance,
n permit re cures th, altos impmw,ticermitt.or repair any nmmero /^ \
—z'a priors iuissnsedIn lusm 1.due ladappliam for Richlrrmino Blew,Law harterl
££ < (co mencin used pumuent a Ne of Disler of Ne Contractor.Lkenu Law(COCA)or q.Ft. Floor Area Valuation
y $ (commencing with SenionJOW)n(Division 3 o lM1C Buzincas and Profcuiom COCA)or j
c .- disk he is esempt tho from and the basis for Or.alleged exemption.Any vhdmi n of
Section 703LSbyany Applicant
rapesmltsubjectstheapplicanuoacivilpcntlryof Occupancy TYPenot.ore than fibs hundred
dollars
($5 . 326N tero0
❑I,As owner of the property,or my employees with wages As their role compensation,
will do be work,and Ne swcere is nut intended At offered for ale(Sec.JON,Business r.
and Professions Code:The COnuacn toes Licetue law donot apply a an owner of Required Inspections
property who builds or impmvu thermn,and who does Such work himselfor through his
own employees,provided that such improvemenu art not intended Oroffered far sale.if,
however,Ne building or improvement B mid within one year of completion.the owner.
builder will hats the burden of proving that he did not Wild or improve for purpose of
sole.).
❑I.as Owner of the property,am exclusively contracting wish licensed contractors to
eonwet the project(Sac.7014,Business and Profession Code:)The Conusernra U. .
team law does no apply to an owner of property who Wilds or iropmvn dmeon,and
who contracts for such projects with a eontnnor(s)licensed pursuant to the ContraMM's
License Law.
El I Am exempt under See. B k P C for Nis rcamn
Owner Data
WORKERS COMPENSATION DECLARATION
10 1 hereby mina under penalty of perjury oro of the following declaration:
❑I have and will maintain a Ccr ifinm of Consent to self-Imum for WorkersComfeen-
setion,an provided for by Section 3700 of be labor Code.for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Comperus0on Insurance,as paruied by Section
3700 of the LAW Code.(m the perrormance of she wmrk for which Nu permit is laved.
My Wonc�rs Cam enation lnunnan ler end Policy nu Wrae:
Carrier. No.�
ERTIPICATE OF EXEM11hON FROM WORKERS'
COMPENSATION INSURANCE
front secrian aced not he completed If the permit u term=hundred doll¢¢(SIM)
err IASL)
1 comfy that in the performance of 0w work for which this permit is issued,1 mall not
employ any person in any manners as an become subject o the worlaus CorepenaRon
Laws of CAifornia.Dem
Applicant _
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Workers COmPewtlon provision of the LaMr Conk,you most
.J O forthwith Comply with Rich provision or Nu permit shall be deemed evoked.
z q CONSTRUCTION LENDING AGENCY
'T+ Iheeby affirm Net Vert is a constnctinn lending agency for Ne performance of
Ci n�i the work for which this permit is issued(Sec.3097.Civ.C.)
W A Lender's Name
Z LaAderS Address
U C) I certify that I have read this application and reuse bar Ne Steve,Mfoan.0n 11
ISO t" correct.I A&=to comply with all city and county ordinances and rote laws relating e
Wilding conSwction.and hereby wNonse representatives of his city m Motor upon the
C)
U
cn Shove-ms,judgdproperty Tori expenses
purposes
gL
WC)agree to Ove,indemnify And keep hom leu IW City of Cupertino against
Z incDities,judgmentsecosuong es penes which tory in my way accrue against aid City
U z in consequence orthegr ring Of this it.
APPLICANT D ANDS A ILL COMPLY WITH ALL NDN-POINT Issued by: Date
SOU R ONS. S -
Re-roofs
era o eSHAZARDOUairS MATERIALS DISC S Date Type of Roof
Will NM applicant or fume building eccupam Smreo dIs havardous mete dal
AS defined by she Cuperim.Municipal Code,Chapter 9.12,and the Health and Safety
Cale-SMMRon 25532(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yn No
Will NM epplielm or Nam Wading Occupant we equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7D �n
azamnua air coraonanAsdc11 d by rhe Bay Arca Air Quality Managementall new materials for inspection.
t7❑Yee NoI haw road the ha:Noes materials equiemsnu under Chapter 6.95 of Ne Califor•
lN&SafnyC n253115.255J d255N.l undanmad thuifNc Wilding
tcu arty t,that it u ponilitYnnotify Nc oaupant of Nc
m m et pd m' ofa Cerdfcate of upancy S' nature of Applicant Dale
o mlhonaetl.,CAP, Date All roof coverings to be Class"B" or better