01070118 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU1 DIADDRESS PERMIT O
1040NG N
0 STELLING RD MISSION CONSTRUCTION 01070118
AAF�1 °SEC RIM FINANCIAL 613 BAY VIEW DR
AP ATE gy3B00,
PHONE: SANITARY NO. CONTROLNO.
(831) 688-1573
q zO ARCHITECTIENGINEER: BUILDING PERMIT INFO
kL"w— BLDG ELECT PLUMB ia i LJ L.J IJ I
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Z S rn Z LICENSED CONTRACTOR'S DECLARATION Job Description
OZ_m Ibcrebyaction that lamlicensed under provisions of Chapter add mmencnse TEMP POWER.
with Section 7L4l d If Jof the Business and Professions CW,and my license
si y ism a, (ince and ett
rc
as a License Class Lic.9 7�q 9 34 -
Sp60 Date Comram �.KS:z, nW.
a{i, CTP11lIALE®
LL 0 ARCHITE 'S DECLARATION
1 understand my plans`hull he used as public records
w aexp Y Licensed Professional UL 2 6 2001
as OWNER-BUILDER DECLARATION
u'S12ia 1 hereby ofErm that 1 am exempt from the Contmaor's License law for the
(_Z< fnllnzvingeacm, (Section 7031.5,Business and Professions CWe:Any city nr county- 0
cc va,h pi n perms m conorucL alter,improve,Jcmollsn,or repair any structure ILDING
i
3 poor to its issuance.also requires theapplicam lin such perms mfiles signed smtament. rA -
'hat heislicensed purmant to the provision,of the Contractors License Law(Chapter 9 3'5310�t0 bl4gry&a,r` f e , • Valuation
(commencing pith Nation]000,of Division J of the Business and Professions CWe) # c . sC'. •ISz.>..-Ll ;
or that he is azempr theratio n and the basis for the alleged eximp ivin Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than rive hundred dollars(S500). 10 3 ABN t�ktg}Wer Occupancy Type
01,as do net ofth,property,ormyemployees with wages istheir sale compcncnhon. 304 - ROUGH ELECTRI AL
-will do the work:and the'stiucmre is not intended or offered for sale(Sec.7(4{
Bueimels'and Professions CWe:The Compatriot',License Law does not apply m an Required Inspections '
owner of,r.,rly Who builds is improves thereon,and who does such work himself
mfla
or through his own employeesprovided that such improvemenrs arc no intendedrhor or
'
,offered for sale.If,however,the buildingeni is sold wittirn one � f --
completion,the owa>Isullder will have the burden of proving that he did not Wild or
improve for puryose of sale.).
co I a:toxionofffi.pmpc.7 am Buss exclusivelycommand,with adea Th tracrers -
n.ase the prosect Lapp ]to a Business d eProfessions CW '1 The C ova barren. 1
Linux Law does not apply.poj owner th prop,ny who builds or improves thereon,
_Cowhoconverts!mmets.projects witb.a.romractor(s).licensW pursuant.m the. . .._.. ._. _._.-_ .._ . . .. ..._._ .___. ..,_..__..- _. _ .._. .. _.
Contractors License law.
[I pt ude
I am exemnr Seca :B&PC fm mis amom
n
O• ir D,itc' •.
w I• ,..WORKER'S COMPENSA'i ION DECLARATION
1 hereby affirm under penalty of perjury one of the following declamtims:
❑ I have and will'mainmin a Ccnili,atd of Content to self-insure fur W..ker',
Compensation. co-provided for by Section 37W of the labor CWe, for the
_ - performance of the work for which this pefmit is stand.,
is
M1ave and will mainone Worke s Compensation In umnte.as aquircJ by Section
J)IXI of the L,M1sn CWe,for itse Mrlbrmance of thi work for which this permit is
iew d MyWorker sC pe 'i I w c unJP l y M1e arc:' - - - _ ., w^ .•
Carr _s. t ..Por yN
nIsl ,s CHI IIFICATION OEEXEMPTION FROM WORKERS,
r i ..COMPENSATION INSURANCC
u' L (Thsiucti;,i ad not bcamicilcted fits,permit is for to hundred dollar
IS I No or less I„
1 lcnfy that N peens c fth kfor wh hth.pe lis issoW I .. .;i• t
shall t stop y a.yy is on9n y marine o .}p co first t he Workers _
bccomCeEubOel %Y[GSSfl4 Pate —1 1 _ ... . .. _ . . .. _. ..
Gm ns tont .. ... . . ... ... ..
NOTI
..
Applicant
Z APPLICANT.If,aftera k g thisC n f to of E e—GTo t, a should
j to the Workers Compensation provisions of the La r CWe,you must
C)-� forthwithtscomply with such
provisions othis
t th permit shalt ebedYf deemed
pe
itod
F ' . .
CONSfRUC`HON LENDING AGENCY 'o:
ncnda ._. . _ .. _. ._ . ... .,
= Z Lender's Address - - ,•
V � 1 c ncify tine I have read this nppliation and on.that the above inlnmatlon is
tzz E:. cwiecr.1 agree to comply with all city and county ordinances and state laws relating
fJ rebuilding construction,and hereby authorize apresendideesof Ibis city roamer upon
W the bis t sed Impede for inspection purposes. _
F•'.p, (W)chilies,to W
' e mfy and k ph I cs th City olC penim,against
VI liabilities j dg m t J expenses which may in any way discgdunst said
U. ^ Cry < n. qac ec ttheg yy g[I lh LNPdI
APPLICANT UN IS 6AND WILL COMPLY WITH ALL N N-P INT / 7
souacE Y, +'� ! ? Z Issued by: to
signator rApp'unVContmdmt; : ate' Re-roofs
p f1AZARDOUS MATERIALS DISCLOSURE
'nln llpld tdrw b 1a'r.g' 1 t n h dlefi Wn s t I Type-of Roof
Code dth Caput Muri<p ICJ Ch pt 912 dthH hh rods ( y
Code Section 355724I _ ` n t a r _ `
ire )` " � a' All roofsshall be;inspec[ed.prior to any roofing material being installed. ._
Will the ppl r t m building , p t Lorequiparlart ordevicas which If a roof Is installed without first obtaining an inspection;'I'`agree to remove
h' d us r con W tits os Jef d by by Day Arc A o al ty manage nem
n t tet \J all new materials for inspection. Applicant understands and will comply with.
❑Yrs No all non-point sou a reg u do
" 1 n5ve,rtadnhe boundless miicrild,requirements under Chapter 6.95 of the
California Health&Safety Cade.Sections 25505,255]7 and 25574.1 undwstand that,
f the hhllding doe,concurrently hand a tram that it is my responsibility vi nmiry the
°iupant of the kquirimenii which most he met prior to Alicante of a Cenificute of
ctapan!g. % Signatu of A ' ant Date
Owner -uthorize gem t 'I" - DaaT- -- All roof coverings to be Class "B" or better - -
:i• -ii • .,;.;... :. . - - 1 - -- OFFICE-- -. .. .. .. _ .- _ ...