03120101 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTpR IIYTURMATXON
BUILDINGADDREW: _ DEBCOR INC PERMIIN003120101PR q PTRT.T.Tua PL)
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NAME: PERMITISSUEDATE
C( E: SANITARY N0. CONTROL NO.
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ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
HOZ, LICENSED CONTRACTOR'S DECLARATION JobD 1 IO
ba I hereby affirm that 1 am licensed under and
Floc ns of Chapter 9(commencingm sis - ���®
with Section]Otto)ec Division Sof the Business and Pmfcaiona Code.and my license is
in mlmreaand erea` ADD GARAGE 469 SQ. FT.
D,
0 Dam Clus LIc.r
`~° °ate ARCHITECTS APR 2 0 2004
ARCHITECTS DECLARATION
� UIundenunJ my plans shell he used as public records
al
S wk. Licensed Prnhencnal BU
03 OWNER-BUILDER DE CLARATION BUILDING
0 q I naso ,(firm Nal 1 oro exempt from the Contractor's A License Law far the
i00 following reason, errant 711]15,Businessand mprve,derma Ca lc:Any city ar county
$ which require,a petrol,"tone am a@q improve,Jemnlis i or repair any structure
is Wi the iuu.nc malxarayuires the applicant fur sueheceowU ems w(Cltemem
�°
Winthewit PSectio°olhc of Diviansm thea B onscmrind Proflsw(Chade)or Sq.Ft.Floor Area Valuation
$ (commencing exa epwith c.1m]add of Division r Atha i,e inessand.n.A inns Cade)or
y Net he is exempt therefrom and or beau for be Waged exemption.Any vinlasion of
Out a Ourch five
any applicant fon petimil subjects the applicant to ac,vil pcnahy of 3VDL nv�ucp'CarOO Oem anC 'I' e
Out mase Nan five hundred dallam(25007. P y YP
❑Lu Owner orlhe property,army employcea with wages a thehmic compensation,
will do the work,and Ne stnclum is not ineadml m offered for sale(Sec.7044.Business
and Professions Code:The Conuacmr's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself ar through his
own employees,provided that such improvements are not intended or offered formic.If.
however,the building or impmvemem is sold within one year of completion.the owner.
builder will have the burden of proving Nat W did not build or improve for purpose of
tide.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
consuucuhe project(Sec.7044.Business and Professions Code:)The Contractor's Lb
came Law does not apply to an owner of prvpeny who builds or improves thereon,and,
who com.cs IN such projacu with a cmdr,ctorW claimed pursusntro Ne Combustors
License Law.
❑lial Sec. .B&P C forth,,arm
a Die/ Date
WORKER'S 9OMPENSATION DE TION
I hereby M.under penalty of perjury one of Ne 011owmg declarations:
have and will maintain a Certificate of Concent to elf-insure for Workers Compete
a floor as provided for by Section 37W of me"We Code,for thtma
e perfance,of the
work for which this permit is iaucJ. -
❑I have and will maintain Worker's Compensation laumncn,m required by Section
37W or the Labor Code.for are performance of the work for which this permit is issued.
My WarkeYs Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed irms permit is forone hundred dollars L000)
or less.) Iv
1 certify that in the performance or the work for which this permit is Issued,1 shall not
employ any person in any manner sm a to became subject o the Workeri Compensation
Laws of California.Data
Appfients
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Income subject to the Worker',Compensation provisions of the Labor Colt,you must
.J O forthwith comply with such provisions Or this permit shall W deemed revoked. `
z CONSTRUCTION LENDING AGENCY )
y. I hereby affirm Nat there is.construction lending agency for the Performance of -
C
be work fur which this permit is issued(Sec.3D97,Co.Q
Q Lender's Name
a z Lender's Address
U Q 1 certify Nat 1 have read this application and seem that Ne above calumniator I$
O'U Cabinet.1 agree to comply with all city and county ordinances and state laws relating to -
buing '/
ddconswetion,and hereby autbodm representatives or this city to enter mean the ///...
LTI ahavcmentioned property Car Impaction Paioes. / 1
(We)agree to save,indemnify and keep harmless the City of CONali l against
I, /
,`.., , liabilities, costs and expenses which may In any way accrue alcohol said City
of the goonfing,
C.) z APPLI NCeUNDERSTAN of IAND WILL COMPLY WITH ALL N N.POINT Issued by: - Date
S
- SOU ULAT�� S
s12 3 Re-roofs
Si emre or Appcicantl muncelor ate—
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will Ne applicant or future building Occupant stare or handle hi ardoos material
Is dormej by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety ,
Code.F,,dmc 15532(.)? / All roofs shall be inspected prior to any roofing material being installed.
OYa.
I
Will the aPpImam ar mwre building Occupant m equipment or deices which If a roof is installed without first obtaining an inspection,I agree to remove
hozallout dr conummants a do vcd by the Bay Arca Air Quality Managcmcnt all new materials for inspection.
�/- rlet4 � '
❑Yes
I have read the hamrdousmaterials myuiremegu under Chapuric.95 orthe Califor.
nice Halth&Sarin' c cyytons 255(15.25573 en�Y255J4.lundcrsundiladthchuilding
Jars not come il h 'fnant.tha,lu ty oaihility to entity the9acueant nl the
rcyu,remcnu Id bcmetptionul canraCemficaaorOc6paay. Signature of Applicant Date -
/` All roof coverings to be Class"B" or better
cr ulhorircd agent - ae