03110047 CITY OF CUPERTINO t ••' �+*.�, �a ` t F '" :' v i
BUILDING DIVISION PERMIT +^`C ONI14UUiV9RgNFQRMATION
B UILDING ADDRESS: C & D FREITAS CONSTRUCTION PERMIT N003110047
6S6 RANDY �.N
R'S NAME: 23610 MORREL CUT-OFF RD PERMRISSUEDATE
TOM & NOELLE MATH 2003
DNE' (408) 353-1228 SANITARY NO, CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC14
l a c LICENSED CONTRACTOR'S DECLARATION O O O
e U I hereby affirm that 1 am licensed under provision of Chapter 9(commencing - Job Description
`,� with Scnion]QM))rf Divi,ionJa(thc Busitiyss and Pmfaoim%C.dc.andrn,Imi.ia
spy in full fnreLa6doften. ✓ REVISION--IN HOUSE USE ONLY
I a q Z License Class LicmmrXsy�
e" Oam ARCHITECTlot RATION NO -NEW PERMIT ISSUED/ ORIG. #02110152
C f uptic..DDd my plans shall he used as public records
>yU
'WLicensed Pndcssionel
g OWNER BUILDER DECLARATION
,I I Wmhy affirm that 1 am eMm,I form the Contractor',Litems Law for the
00 following mason./Section 7031.5,Business and Professions Code:Any city Or county
$ which requires a permit in construct,aper,improve,demolish,or repair any structure
-¢e Prior to it iamance.alsr toitires the applicant for,uch permit m file signed statement
pp that Do is licenord pursuant to IN ponvisions(it thee Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation $0
(commencing with Section 7")of Division 3 of the Business and Profcesinus Crile)or
i Nat he la exempt them(mor and IN basis for Ne alleged eaempdon.Any violation of
Section 7031.5 by any applicant for a permit ubjccu the appiicinuo a civil Penalty of 3 IA8020divt73et00 Occupancy Type
not more Iran five handled dollars(SSW). P Y YP
❑ I.u owner of IN property,or my employee,with wages u Heir sole compenudon,
will do IN work,and the swnum is not imendcd or offered for sale(See.7044,Businers
and Pmessions Cade:The Contractor's License Law does not apply to an owner of Required Inspections
property who build,or improves thereon,and who doeuuch work himself or through his
own employees,provided that such improvcmenu art notimmmde l m offered for sole.IL
however,the building or improvement is sold within One yesr of completion,the owner
builder will have the burden of proving that rte did not Wild or improve for purpose of
bQ llas owner of the property,am exclusively contracting with licensed conumtom to
coodAcuhe project(Sec. 614.Business and Professions;Code;)no Conm.cmrt Lt. �g
carom law docs not apply to an owner of property who Wilds or improves thelean.and, C��
who contract for Such project with a cono.csor(s)licensed pursuant to the Camnctnr', \
License Law.
❑tem nem derBPCfor this mason
137Mr R Al /•,rJ
Dain -D5
WORM'S COmmervSATION�AT10 \\'\
I hereby affirm under Fealty of pc jury one of the following declarations: v
ave and will maintain a Cenifinm of Consent m self-insum for Workers Canham
,as provided for by Section 37W of Ute labor Code,for the Performance of the
for which Ni,permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,for the performance ofhe work for which this Permit is issued.
orker's Compensation Inwnna carrier and Polity number am:
r. nliry No.: _
CERTIFICATE OF ON FROM WORKERS'
CNE A,,"INSURANCE
(This section need nol hecompleted i(Ihe Permit is for one hundred dollars(SI W)
or less.)
1 cenify that in the Performance of the work for which this Permit i,issued,I shall not
employ any person in any manner m u b become subject m the Workcri ComPesnation
U.S of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificem of Exemption,you should
become abject to the Worker's Compensation previsions of the Labor Code,you must
O forthwith comply with such provisions onhis Permit shall W deemed minted.
Z` CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the perfurmancc of
the work for which this Permit is issued(Sec.3097,Civ,C.)
Irl Q tondo's Name
'Sa Lenders Address
J 0 1 xnify that 1 bait read this application and sum that the above information is '
tarU burleingconcetn comply hith all rebyarryand county
epresou inaaes and rut lawsr upon to
the
0 V building construction,i ro and
ry hereby anthonp represenmtires of this city to anus upon the
G ,hove-(We)area 1.swfindmnify an keepha
(we)agree to arc,indemnify and kith harmless Ne City of Cupenst s against /
incon=qunccofthecosuand orpenusmit. may in any way aecroc against rid City
(„)z in conscyucncc a(thegmn&NDSthis permit /OJ
APPLICANT UND NOS AND WILL COMPLY WITH ALL NONPOINT Issued by: Date
SO R• 9WIONS. /'/�li3 m
Re-roofs
gnemrc o(ApplicamUConmcmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hvardous material
donned by the Cupertino M*pal,Code,Chapter 9.12.and the Health and Safety
S❑IYes 25332(1)? No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haasdnu,air contaminant dcfncd by the Bay Ale.Air Quality Mangcmcm all new materials for inspection.
i,vin?
❑Yee Nn
I have lead the hasallous mmcrials requirement under Chapter 6.95 of the Califon
nia Health&Sdety Codc.Rcu=25N)5,23533wd25534.lundcros dNmi(IW Wilding
Jan oat curtenhic hose a mnanh Nat h u my respousicom m wufy tM cecupant of drt
requCmcn men aniBe,ter "col"y. Signature of Applicant Date
war.1 uth.h.dagent �/7lDat� All roof coverings to be Class "B"or better