02110084 CITY OF CUPERTINO *�o. *i- "•,� tR .6�r.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: i
Bul 1914HELLY DR SQUARCIA LARRY G AND YO DAMITN02110084
oWNSWARCIA LARRY G AND YOLANDA APPLIcATp7sP11"3Tr2002
]ONE: SANITARY NO. CONTROL NO.
ARCIIITEC'UHNGINEF.R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MSCI]
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LICENSED CON'IRACTO,proDECLARATIONs
u M1crehy affirm Nm I am IicenvA under Onrvisions o!Chaffer 9(commencing WATER HEATER AH� ,�R1T
�m6 with Seninn)IgkB of Division 3nf NC Ousinesa'snit l'r..foxinns Ctdgandntylicenseis
< in fullImecand effect.
b—Z License Class Lic.N
G m r p Dam Contractor
CHITECT S
ATION
OkE ce< Iundersand my pl ne hal M used as puhlicrecend,
to
IF�shol- Licensed Profexsional FINALEM
OWNER BUILDER DECLARATION
I hereby of on that I am exempt from the Contractor's License Law for the sa gri.POq®9� �OQ�
to p 0 following reason.(Section 7131.5.Business and Professions Code:Any city or county H
e, which requires a permit hr consumer,after,improve,demolish,or repair any stmeture
�Zr pnnno its issumme.also requires the applicant harshen penninn file a signed statement
SS < that he is licensed pueuaetothe provisions oftheConnector's License Law(Chapter 9 3*9&t1t0�34AEBa
Y�$ (commencing With Section]]gg)of Division 3 of the Business and Professions Cook)or L4gYl' �NJ
_ that he is exempt therefrom andNe basis for the alleged exemption.Any violation of �UY�I��Q�C,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nm more than five hundred dollars($500). 506pN NGAS TEST ccupancy Type
❑I,es owner of the pmpcny,or my employees with wages as Nev'sole compensation,
will do Ne work,and Ne stmcwre is oat intended oroffertd fonale(Sec.7 7W.Basineu
and Professions Code:The Contractor's License Law does not apply to an owner of CgUVe ❑SpeehOns
property who builds or improves thereon,and who Janes such work himself or through his
own employees,provided that such improvements arc not intended or offered for We.IL
however.fie building or improvement is sold within ane year of completion.the owner.
builder will have the burden of proving that he did not build or improve for purpose of
soled.
1,as owner of the property,am exclusively contorting with licensed contractors to
construct the project(Sec.]Baa,Business and Pm esiam s Cele:)The Contractor's Li.
nae Law does not apply to an owner of property who builds or improves themon,and
contracts Ro.imch projects with a contmctons)licensed pursuant to the Contractor's
nw Law.
Ile exempt under a ,B&P phis res
.O. Dam
ORLER'SC SATION DECLARATION
I hereby affirm erotic nalty�i perjury one of the following decluati s:
❑ I have and will maintai acentric re of Consent to selpmarne for Worker's Compem
W nn,as provided for by IMI of the Ichor Code,for Ne performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurntt carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seethe need not becomplered if rhe permit laureate hundred delfus n](p)
,it less.)
1 certify that In the performance ape ton'a ismed.I hall not
employ anypervm'/any mannc ol/T^xjtar w'ul ' kers'Cnmpcnsmion
Lawsol Califoor 6a
Applicant
NOTICE TO PLIFlUlm'
making this Cenilleme of Exemption,you should
become subjont m the Wn cr's mpensation provisions of the Isbnr Code,you most
OO forthwith comply with ser no innnr this permit shallbedccmcd evnkted.
'zz "" CONSTRUCTION LENDING AGENCY
Ihereby a iron that there is a construction lending agency lor the performance of
Qui7 the work for which this permit is issued(See.3097,Civ.C.)
4 a Under$Name
.7. z Lender's AdJmss
U 0 1 cenify Nat I have read this application and state that the have information is
II. P correct I agree to comply wit all city and county ordinances and state laws relating m
0 U building construction,and hereby authorize represenutives of Nis city to enter upon the
W above mentioned property for inspection purposes.
0a (We)agree to save,indemnify unit keep harmless the City of Cupertino against
h liabilihes.judgments,costs and expenses which may in any way acme against said City
U z is conscyuencc of be min"
of Nis perm it
r APPLICANT TA
PL
AND WILL COMPLY WITH ALL N -POINT Issued by: Date
SOURCE RE LAT
roofs
SigmalovilifAPPIican"Com ,or
Dare
HA]. DOU MATERIALS DISCLOSURE Type of Roof
WIII Wu applicant nr uilJing cecupvm sturaor hunmo haemnus memrlol
as defined by the Cupenino Municipal Chapter 9.17,and the HeaIN and Safety
Cate.Dyes 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
WIII the applican or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardous air conumi antsaz Jef ythc Bay Arca Air Quality Management all new materials for inspection.
DistricR
Dyes
I have nail the emous mamnalsrequirements under Chaprerri.95 of Ne Califor.
not HealthXSafetyCmt.Scmoru25N15,25533 nit 25o 1.1 unikrs. d thu ifthe Wilding
doe's nm currently have move Nvr it is m"ah ibility to notify the encu tof the
eyuircmcme which .t an eCcniftcate of Ce y SI ature of Applicant Date
owner or authnrirc0 ogee D/ate All roof coverings to be Class"B" or better