04040069CITY OFCUPE2'1'INO
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BUILDINGDIVISION PRRMIT
CONTRACTORANFORMATION �c
BUILDING ADDRESS:
1358 S STELLING RD
DEBCOR INC
PERM IT N`04040069
ER'S NAME:
PERMIT ISSUE DATE
DEBCOR INC
1358 S STELLING RD
04/12/2004
ONE:
SANITARY NO. CONTROL NO.
ARCHITECIICNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L 0
LICENSEDCONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
P
with Section 70f0) of Division 3 of Ne Business and Professions Code. and my license is
in fell force and erfen.
REVISION--TRYSS GALS
License ClassLic.Is
Date Comment,
NO NEW PERMIT ISSUED/ORIG. #03120101
ARCHITECTS DECLARATION
1 understand my plans shall W used as public records
Located Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following moron. (Sect;.. 7831.5, Business and Professions Code: Any city or county
which requires a Permit to construct. alter, improve, demolish, or repair any structure
prior in its issuance, also requires the applicant for such Pennit t. file a signed sulcomm
that he is licensed pursuant to the provisions (or the Contractors Lia.se Law (Chapter 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Section 711(18) of Division 3 of the Business and Professions Code) or
Beat he is exempt tlrere8om and the basis for the alleged exemption. Any violation of
Section 7831.5 by any app) icanl for a permit subjects the applicant to a civil Penalty of
Nu
APN PNNu
Number
Occas ane �
not more man five hundred dollars (S50IB.
36617105.00
P y Pe
El 1, u owner or me property, or my employees with wages ss their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 704x, Business
Required Inspections
and Pmfessians Code: The Caput ori License Law doca nm apply 1. an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees. provided that such improvements are not incndcd or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner-
builder will have the burden of proving mat he did not Wild or improve for Purpose or
A
sale.).
❑ I, as owner of the em ,elusively contracting with licensed eanvunoa i-
See 70y,
construct the project (Sec. 7844, Business and Code:) no Cs mh Li-
Law does notapply mset owner o(prnperty who buildsorimproves Corton,so,
property who brei olmo d
who
who contacts for such projecB with a contractor(a) licensed pursuant to one Contractor's
\r
License IAw��^///���
❑lamas RmptSu,Wcy�cc.��Bk PCror Cis reunn
I�—s (ro:/W(Oi�HiLRER�1
PENSATIONCID TION
1 hereby affirm under Penalty of perjury one of the following dtclamtk ns:
t
❑ than and will maintain a Cetttfieale of C.nunt to ul6inwm rot Worker's Compere
sation, As provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
ED 1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of One labor Code, for the performvtce of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(This seclian need nut he campleud if the Permit is Barone hundred dollars ($100)
or lass)
1 certify Cut in the performances the work for which oris Permit is issued.) shall not
employ any Person in any manner so As to Wcom, subject to the Worker; Compensation
,
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cenifcam of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall W deemed mocked.
CONSTRUCTION LENDING AGENCY
I hereby afore Cat data is a construction lending agency for Ce Performance of
the work for which this permit Is issued (Seco XP17, Civ. C.)
Lender's Name
I<nder Add./1
I cenify Nat I have read this application and sate that Ce above Information isf—
concn. 1 ensue to comply with all city and county and state laws .]Ann, to
building ennslrvdparand hereby aumon rominscor
r
rposes. moves or oris city m enter upon the
aabilities,judgmacd pmPmly for inspection p
(We) agree to throe. Indemnify and keep barroom the City of Cupertino against
whichaC9.
liebilitics,jodgmcn¢.com and no'tnsu which may in any way accrue against said City
inPPnuquenet of IhisD
DERSTANOSfo
WILL COMPLY WITH ALL NON-POINT
issued by: Date
LATIONS.
Re-roofs
Type of Roof
VdIftiffe al'Applicart/Coppictor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building.ccupanl store or handle harardome material
As dented by the Carmelite, Municipal Code, Chapter 9. 12, and the Health and Safety
Jc, Scnlon 25532(x)?
❑ Ym fIW'
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant orrulumbuilding Occupant use equipment ordevimswhich
emit ha ardous air contaminants As defined by the Bay Area Air Quality Management
all new materials for inspection.
Dismicl7
❑Yes 1jN
1 have read the he ardous materials requirements under Choutr 6.95 orthe Caldr, r-
nisHcalthSSafctyCode.Sections 25N)5,25533 and 25534.1 undcamnd ad Bob, Wilding
docs
Na it is myre, mibility to notify the acupant or Ccrciont,orrdetoiSun
or. rt10n ay.
Ahd
Signature of Applicant Date
Y
roof coverings to be Class "B" or better
I DowAll