03100113 CITY OF CUPERTINO
BUILDING DIVISION PERMITCON1'RACTORINFORMATIO1 -`fi
BUIL DING ADDRESS: EASTMAN CONTRACTING, INC PERMIT NO.03100113
ER'S NAME: 1418 DOUGLAS ST PERMIT ISSUE DATE
JNE: (408) 971-9000 SANITARY 2 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o O LICENSED CONTRACTOR'S DECLARATION
i U U1 hereby affirm that 1 am licensed under previsions or Chaplet 9(commencing Job DescripLn
iwith Section 700s))of Division 3 ofthe Business and Professions Code,and my license is ®�
in full force and effect
License Class Lt..a WATER DAMAGE REPAIR L
t-
Dan -®�®
qq ARCHITECTS DECLARATION ILI
V
i g 2004
1 understand my plans shall be Latin;public records ,IIA(
sdG
'4 w Licensed Professions]
o S OWNER-BUILDER DECLARATION t
�<q 1 hominy aDiirm'hat I am exempt room the Contractor's License Law for the Suit®/e.G
too following reason.(Section 7031.5,Business and Professions Conic:Any city.,county IVI
e m which Minims permit us construct,altar,improve,demolish,or repair any structum
s�'^ Priori,,iu iuumre.alm requirca'he applicant for such permit to rile a signed statement
Y
that licensed pursuant ion7 the provisions of the eBusins Common's License Law(ChapterCode)
Sq.Ft. Dor ICs VaU t100
2� - - -
(commencing exemith Section]000)of Divisiofr the
the Business and ProfessionssistOn or
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that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rove hundred dollars(55007.
❑ 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the sdnnme is not intended or olTered inside(Sec.7044,Business Required Inspections
and Professions Code:The Corporation's License Law docs not apply to an owner or _ q p
property,who build&or improves thereon,and who does such work himself or through his
own employees,provided that such improvements ere not intended or ofrred for sale.If,
however,He building or improvement is old within one year of completion,He owner,
builder will have the burden of proving that he did not build or improve for puryose of
rowner of the property,am exclusively contracting with licensed contractors to
ucuhe project(Sec.7044.Business and Professions Cade:)The Conuacta'a Li-
cense Law docs no'apply to an owner of properly who builds or improves Hereon,and
who common for such pmjecu with a conuaz'ons)licensed pursuantto the Commdur's
Lkcnse Lew.
❑ I em exempt under Sec. B&P C for this..no
WORKER'S COMPENSATION DELLA N
1 hereby affirn under penalty of pe jury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn-
&mion,as, for by Section 3]00 of He labor Code,for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3]00 of He Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complemd itlhe permit is for one hundred dollars(5100)
or has.)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any mannerso az to become subject to the Workcri Composa'ion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become Subject to the Workef9 Compensation provisions of the Lahor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
I Wethy salon that Here is a construntion lending agency for the performance of
Ya He work for which this pomid Is issued(Sec.3097,Cie C)
Zl Q Lender's Name
aw,z Lender's Address
Q 1 minify that I have read this application and stale Hart He above information is
y correct.l agree to comply with all city and county ordinances and state laws misting to
�O building construction,and hereby mncrire mirmacn'mives of this city to enter upon the
G show-memmand pmrooy for inspection purposes.
(We)agme'o save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments,costs and expenses which mayin any way scene ago out
aid Cidy
J 7 in consequence of He guarding of this permit.
a APPLICANT U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE RE ATIONS. f/b•
I Re-roofs
Slgnanr f n nr Dam
HAZA DOUS MATERIALS DISCLOSURE Type of Roof
r l the applicant or future building occupant score or handle ha Mous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
f. []YSazss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes )'j�Vo
Will the apjt(Iicant or future building occupant no equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i.11,�'a,smduua' air cpnmminants a&JeOnnd by the Bay Area Air Quality Management all new materials for inspection.
,
❑Yes KNo
I have rad He h n-ohus materials miloremanb under Chapter 6.95 of the Califor-
niaHcalth&S cdy Codc,Sttdons 255x15,25533 mJ255J4.lundcrsund thedif HC Wilding .,
doe'n o to In 'Lis my responsibility to oudly the<upmt of the
rcyui ion must be mei prior w issuance of a Certificate of Occupancy. Signature Of Applicant Date
/O /3 O
o neva horimdagent timeAll roof coverings to be Class "B" or better
Ovh i�