04020007 LCITY OF CUPERTINO
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BUILDING DIVISION PERMIT0?\T1�Cf.4T�A�ZNI'ORt3'1ATION
LDING ADDRESS: WM H FRY CONSTRUCTION COMP IT"04020007
SR'S NAME: - PERMITISSUEDATE
to'
SANITARY NO. CONTROL NO.(408) 996-8173
HITECDENGINEER: BUILDING PERMIT INFO
B DG E ECT PLUMB MCH
u0o LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed nd previsions of Chapw,9(commencing —" Job Descrip
O infullfordp7q(Nyee[./Sion]oflheBui ..endProfcssionxCodc,andmyliccnscis � NALE®
^<^ withs cti �1fdeflect. -
5qi ucenseaGss
Lie. SZo7Sf BATHROOM REMODEL
M H� Date l ARCHITECTS D or ATION� U
D E U 1 understand my plans aM1all he uscdl uhlic records --_—„ :26
/ 2001
rrc tl3, Licensed Professional OCT1, tJ al
L OWNER-BUILDER DECLARATION BUILDING
g 8 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 703 1.5,Business and Professions Code:Any cityor county
which nurtures a permit to construct,alter,improve,demolish,or repair any structure
°$ poorm its issuance,also requires the applicant for such permit o Gia a signed statement
£ < that he is licensed pursuant to the previsions of the Contractor's License Dow(Chapter 9 Sq.Ft. Floor Area Valuation
y0 (commencing with Section]000)of Division 3 of the Business and Professions Code)or
y Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit subjects lie applicant to a civil penalty of .3�e>D 0 OGGu aDC Type
not more than five hundred dollars a5OE. p y yp
[,u owner of the pmpcny,or my employees with wages u Ncir sole compenu0on,
will do the work,and the sructure is not intended or offered for sale(Sec.7044,Business
and Professions Cade:The Containari License Law does not apply re an owner of Required Inspections
property who builds or improsa themon,and who doesmch work himself or through his
own employees,provided that such improvements are nminteaded or offered for sale.If,
however,line building or improvement is sold within one you of completion,the owner- s
builder will have the burden of proving that be did not build or improve for purpose of
sale -
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the pmject(Sec.7044,Business and Professions Cade:)The Conuazmr's U.
cense Law does not apply to an owner of property who builds of improves Ibemon,and
who contracts for such projects with a contractors)licensed pursuant o the Comnctor'a
License Law.
❑I am accept under Sec. ,B&P C for this ruson
r Date
WORKER'S COMPENSATION DECLARATION
I hereby afTrm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker'sCampen-
satien,as provided for by Section 3700 of the Letter Code,for the performance of the -'
work for which this permit is issued. '
ave and will maintain Worker's Compensation Insurance,u mruimd by Section _
00 of the Labor Code,for the performance of the work for which this Permit is issued.
M Work is CnmPematian lnaunnce carticr'an'd' P�oxlicy number am:
Ca ' Orn n= ra„.t_ Fp3�tvo.: x/9[(27.32 .
CERTIFICATE OP EXEMPI'1iQ�N FROM W ORKERS'
COMPENSATION INSURANCE
(This Account need not uncompleted if the Permit is far one hundred dollars(5100)
or less.)
1 cenify that in the performance or the work for which this Permit is hermit,I shall not
employ any person in any mannerm as las become subject o the Worec ri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making Nis Ceniricatc of Exemption,you should
become subject m the Worker's Compensation provisions of the Latour Code,you must
.J O forthwith comply with such provisions or this Permit shall W deemed resulted.
z`" CONSTRUCTION LENDING AGENCY
[-+ 4 I hereby affirm that there is a conswction lending agency l'or the performance of
C' > the..,it for which this permit is issued(Sec.3097.Civ.C.)
W� A Under's Name _
a z Lender's Address
V Q 1 cenify that I have read this application and sate that the above information is r
1, correct.I agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby amhorise representatives of this city to cnscrupnn the /n' �]
ashove-mentioned ju
dgments.
c costs
far inspection
ees purpowhich ms.
(Wo)agree to sacs,indemnify and keep hannlcu the City of Cupcnino against /Jr/w/\/at�'k/C//' /
eF.th in
equnce of ru,coau and of this esmit. mayinany way ncemc against said City
(„) z in consequence NDERise TAN of this Permit. 2. � �.v
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Is$ued by: Date/`/' L V
SOURCEJGULATI "S.
Stgnamre of Applic HAZARd US MATERIALS DISCLOSURE Date Type of Roof
Will the applicant ser furore building occupem store or handle harerdons material
as colned bythe Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
.Section 25533(a)?
❑Yea ❑No All roofs shall be inspected prior to any roofing material being installed.
Will Ne applican,o,Iphom building aerosol use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.it hazardous air contaminants As defncd by Ne Bay Arca Air Quality Management all new materials for inspection.
'atria?
❑Yes (2 No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Calirm.
nia Health&SafetyCode,Sccdun 35505,25533 and 25534.1 undersand Ihw if dm building
does not currently have a tenant,that it is my mormusihility to notify the Occupant of the
un uircou nts must meted w issumcc of a Cert ricaa cf Oce ancy. Date
Signature of Applicant
All roof coverings to be Class "B"or better
cr
or aahmized agent pate g