03060003 CITY OF CUPERTINO '�F^�* ns 'd" % '�' " •'`
BUILDING DIVISION PERMIT VISO T01k TN ffl MAT, IO ;z
BUILDING ADDRESS: PERMITNO0 3 0 6 0 0 0 3
'4ER'S NAME: """M"2/2003
N MAO H AND PI 1
N[: SANITARY NO. CONTROL NO.
ARCHITEC IENGINHER: BUILDING PERMIT INFO
BLDG ELP,L7 PLUMB MECN
�Op LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I me licensed under prevision of Chapter 9(Commencing
with Section 70M).f Division 3 of the Business and Professions Code.and my license is
n in full fmmand eBen. POOL .DEMOLITION �^�����'�
j n Z LicenseChis Lie,I
ter Dato Contactor
gg ARCHITECTS DECLARATION gg
i53 Iundenundmyplans shallheusedaspublic mmurds J U 2003
D�
Licensed Pn fcssianal
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the BUILDING
E 0 O following noon.(Section 703 1.5,Busiask and Professions Cade:Any city or county
l$ff which requires a permit to conswc4 altar,Improve,demolish or repair any structure
_Z�^ prior in its issuance.also requires the applicant for such Permit o rite a signed sntcmcmsv,,.
that he u licensed pursuant to dm provision or the Contractor "More Law(chapter 9 Sq.Ft.Floor Area $5yyy[IOn
21 Spy (commencing with Section 7")of Division 3 of tbo Business and Profession Cake)or
3 that he D exempt Nee:fmm and the bub for Ne alleged eumpton.Any violation of -
Section 7031.5by arty applican,for aPermit subjects the applicant oacivil Mostly of er 00 Occupancy Type
not mon Nan Ove hundred dollars(M).
1,a owner of W Progeny or my employees with wage u Net sole co eperwdon,
will do the work.and theswcmm ie not intended or offered for made(Sm.7044,Business —
and Professional Code:The Comsacuo's License Law don net apply to an owner or Required Inspections
property who bu ll ds or i m proves Koran,end who does anc h work himself ser through his
awn employes,provided thrombi improvements are not intended oro0ered forsale.If.
however,the building or improvement is sold within one year of completion.the owner.
builder will have the buNen or proving that bo did Inst build or Improve for purpose of
tile.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7W,Business and Profesdons Cade:)The Cumusetor7 LI-
ceue law docs not apply to an owner of property who Wilds or Improves Ihanon,and,
who contracts for such projew with a comrsetor(q licensed punnet to the Comhusoes
License Law.
❑1 am exempt under Sec .B&P C for Ni>reawn
EI � - K 0403
WORKER'S COMPENSATION DECLARAYON
I thereby affirm under penalty of perjury one of the following Galaruion:
1 have and will maintain a Cemifise
eam ofConm to self-iuum for Worker'sCampen.
md,mi u provided for by Section 3700 of the labor Code,for W performance of the
work(ser which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,ss re uired by Section
3700 of the labor Code,for use performance of the work for which this permit is issued.
My Workers Compensation Insurance Carrier and Policy number sm:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if t e permit Is fn one hundred dollen(SIM)
ter leu.)
1 unify Net In the Forme or Ibo work for which this Permit b issued.I shall not
employanyperannfi;tym"nerasslo ubjcctto dee Workers Compensation -
Liwao(C41IfOreiL am b 11 6
APPIIcaA
NOTI s APPLICAN1 17.a ser making this CcnlMnc of Exemption,you should
Immune subject to the Workers Com anation pmvislons of Ibo labor Code.you must
Z forthwith comply with such provision or this permit shalt bo damed invoked. '
OCONSTRUCTION LENDING AGENCY
[�. I hereby alTum that Nen is couwctinn lending agency for the performance of
�i> d c work for which Nb permit is issued(Sec.X)W,Civ.C.)
Ca Uodcrs Name _
.7 Z Lenders Address
U O 1 certify that I have read this application and luta Nat the above information is
F' COMM 1 agree to comply wide All city and county ominanes and sum laws mining in
QU building construction,and booby authorise representatives or this city to comer upon the
W alven-mentioned property for infection purposes.
LL (We)agree to save,indemnify and kap harmless the City of Cupertino against "�
r rte liabilities.judgments,costs and expenses which may In any my seem against said City /\/
U 7 in consequence of to granting of this permit.
�7 APPLICANT UNDERSTANDS AND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATI �v' � � 016
r Re-roofs
ipleture o(ApplicanBCoARDO
HAZARDOUS MATERIALS ,momoS RE oto Type of Roof
Will the applicant or future Wilding occupant nom or handle hazardous material
ss defined by IW Cupmino Municipal Cade.Chapter 9.13.and de HCaIN and Safety
c.Sccton 35533(x)? All roofs shall be inspected prior to any roofing material being installed.
0Yes No
Will the applicant or tutu Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Wameus air contaminants as defined by she Bay Area Air Quality Management all new materials for inspection.
Diurin? r�[��
Oyer Pk.
I have rest the haeamous materials requirements under Chapmr6.95 olive Califor.
nits HCaIthlk Safety Code,Sectiam 75505,35533 and25534.[understand thetif Ne building
docs not curcmly have a meet,Net it u my mapomlhifl w Cantil dm occupant of Nc
nquimmcnts which Wme pdorto its co(a ccni am Occu an . Signature of Applicant Date
_'S
,Iyt. - .o- _ �ihth
Owner or aamadved ascot pato All roof coverings to be Class "B" or better