03090101CITY OF CUPESION -
CONTRACTOR INFORMATION: °-
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
Nr (77
LINDA LAINE
PERMIT `003090101
NAME:
PERMIT ISSUE DATE
INDA LAINE
11/05/2003
r'S
:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
29 = 0
LICENSED CONTRACTOR'S DECLARATION'
I Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
P
with Section 7") of Division 3 of the Business and Professions Code, and my license is
in fell farce and effect.
ADD 1824 SQ.FT./GARAGE 431
Class
FahV�A L
Dow Commuter
ARCIITECS DECLARATION
'
1 understand my plans shall he used as Public records
AUG 30 204'
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 oro exempt from the Contractor's License Law for the
following massa. (Section 1(131.5, Business and Professions Code: Any city m musty
B ILEM
which alter, improve, UCLUM
Fi repair any mumu(
sums a permit constmires
V
0 0 0 0
h remix t
prior In its issuance, alum requires the the applicant permit m ole signed statement
its re the
Sq. F[. Floor Area
Valuation
that thepmvisionsn the Contractor's License
oftheSttacem nProflsonsCodmr9
(commencing exempth Section 7")ofDivisiofr theeged exempt PmfcssionsCodc)of
menlicensed cingwitpSectio 7
'375255'036.00
m
Nat he is exempt therefrom antl the basis for the alleged exemption. Any vinlatlon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Pantry of
not more than Eve hundred dollars (S500.
❑ 1, m owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and Ne structure is not intended or offered for sale (Sec. 7044, Business
and Pmfcssions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himin lfar through his
own employees, provided that such imprawmemis are not intended or offered for sale, IL
however, the building or improvement is sold within one year of cmmpleuon, Ne owner.
builder will have the burden of proving Nat he did not build or improve for purpose of
.to ).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 1044. Business and Professions Code:) The Contractor's Li.
nae Law does not apply to an owner of property who builds or improves themon, and
who contracts for such projects with a contractor(s) licensed pursuant to the, Convector's
License Law.
1711 eaemptunder Sea. .B&P C for this reason
V
or �- Data
WORKER'S COMPENSATION OECL ATION
1 hereby affirm under penalty of perjury one oft c following declarations:
have and will maintain a Certificate of Consenuo self-insum far Worker's Campen-
anion. as provided for by Section 31(10 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, u required by Section
3100 ofthe Labor Code, for the performance of the work for which this permit is Issued.
My Wofket's Compensation Insurance eerier and Policy number am:
Cartier: Policy No.:
_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is Larose hundred dollars ($100
or lCm.)
1 certify Nat in the performance of the work for which this Permit is issued. l shall not
employany person inQa mannlf sn gsfn hp �rslgsubjectto theworkers'Compensation
Laws of California. a (j.�--i-/
Applicant
NOTIC555555 TAPPLICANT: If, after making this Cenificne of Exemption, you should
O
the Worker's provisions of the Labor end., you must
bceom�jea m Compensation
forthwit mply with such orwid.n.nr,hia permits hall he deemed masked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a Conswction lending agency for the Performance of
the work for which Nis pernit is issued (Sec. 3097. Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above simulation is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building conduction, and hereby authorim mpres in atiws of this city to enter upon the
above-mentioned property for inspection purposes.
(We-) agree Is aavc, indemnify and keep harmless the City of Cupertino spinet
liabilities, judgments, costs and expenses which may in any way accrue against said City
[i -a
in consequence of the granting of this permiL.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT
Issued by: Date
S RCEREG ATIONS.�
A�l/r/O
Re -roofs
v/
D
Signadre o ApplicanUCon racmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
ex defined by the Cupertino Municipal Codc, Chapter 9.12, and the Health and Safety
c. Section 25532(a)?
❑Yes �Nm
All roofs shall be inspected prior to an roofs material being
P P Y g g installed.
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 Area Air Quality Managemcm
all new materials for inspection.
is rict?
❑Ycs ku
I have mad the hamodnusmaterials requirements titer Chapterb.95 of the Califon
,
ma Health & Safety Code, Seeuous 25505,25533 and 25534.1 understand thatiftl a building
docs not currently haw s tenant, that it is my responsibility to notify the Occupant of the
rcquimmenes which must b`met prior to issuance ofa Cerificam of Occupancy.
r 41—
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
ser authorizcJ agcnDarcJ