04030232 CITY OF CUPERTINO �Y T ,,miry L " K Y
BUILDING DIVISION PERMITN
TUN ,. - -
BUILDING ADDRESS: PERMIT NO.
040302327- PPTT1jr_1 '
0 NRR'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
l� =
tooLICENSED CONTRACTOR'S DECLARATION - Job Description - - -
I hereaffirm Met affiNet 1 am Incurred under provisions of Chapter 9(commcncing P .
with Section 7'1010)of Division 3 oflhe cuBusiness d Profcaioa Code,and my license is ®
in nerc
' Lt a , AGL34yr REMODEL POND & LANDSCAPE (C
S r? Licnse T Zk.
Dam Contractor. CONTRACTOR: PACIFIC WATER ART I C
RC ITECTSDE Ian J L 6 2004
yy eatanJ ah 1 be u u err s
?yU
3C Liememl Profc . al �1P
OWNER-BUILDER OECLARATIO BUILDING
+� 1 hereby affirm that I am exempt from the Contract is worse Lew for the
i00 following mason.(Section 7031.5,Business and Professions Code:Any city or conry _
u�9 which mquirm a Permit to construct.alter,improve,demolish,or repair any structure
�n Pdonnils iauencc.also mquims the applicant for Such permitm fileesigned statement
ptp�eD t"thei511ccnudpmuanlmlhcpmvislonenI the Contractor's License law(Chapter 9 Sq.F[.Floor Area Valu 000
k $ (commencing with Section 7000)of Division 3 of the good.and Profcsaim.Code)orthat he '7401
Section t70315 by any applicanfore t for a Permibasis tSubje ts r the Na appl¢mrlo a cin. viliolation.1
Penalty of
APN Number Occupancy Typo
nm more than five hundred dollars($500).
❑1,as owner of the property.or my employees with wages u meirmic compensation. 366 5 2
will do the wark..nd townsctum nntimmuded oroaered forsale(See.70x4,Busmen Required Inspections
and Profusalma Cod.The Convectors License Lew does not apply m an owner of q P
property who builds or i mprovm Neuron,and who does such work himsel f or mrough his
own employces.provided that such improvements are winnowed moReud forms,It.
however,the building or improvement is sold within ane year of(Wmpletion.the rus-n-
builder will have the burden of proving that he did rat build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
comtmcl the project(Sec.7044.Business and Profusions Code:)The Contracture U.
come Law does not apply to an omen of property who builds or improve tureen,and
who contracts for such projects with a conuacro(s)licunsed pursuant to the ConwnoM1
License Law.
❑l m exempt under See. .B d P C for this moon
On'
Date
WORKER'S COMPENSATION DECLARATION
1 hemby drirm under penalty of perjury one of me following declarations: '
I have and will maintain sConificate of Come nue ulGinam for Wmker's Compen.
ration,as provided for by Section 3700 of me Labor Coda,he the performance of the
work for which this permit i5 issued.
❑1 have and will maintain Workces Compensation Insurance,a required by Section
37W of the Labor Code,for me performance of me work for which this permit Is issued.
My Workers Compensation Insumen'ce carrier and Policy number m:
'err. SYaG �M//IAIJ Policv^N�..' �
CERTIFICATE OF EXEMPTIO OM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed i f the Permit Is for one hundred dollars($100)
or Ic55.)
1 cenify mal in me performacu of me work for which this Permit is issued,l shall not
employ any person in ray manner az in become subject to the Workers'Compensation
Laws of Calif ecia.Date
App]Ram
NOTICE TO APPLICANT:If,after making this Ccnifrcuk of Exemption.you Should
become abject m the Worker's Compensation provisions of me Labor Code,you most
QZ forthwith comply with such previsions or this permiuMll M decreed revoked.
ti O CONSTRUCTION LENDING AGENCY
'rr Ihomby afErm mat ft.is a construction lending agency for the Kofmmmrof
a;> IM work for which this Permit i5 issued(Sec.3097.Civ,C.)
W~n. Under's Name
W Lender's Address
V 0 I certify that I have read this application and slate mat me above mfmmatim Ica
It, f•' coned 1 agree w comply wine all city and county ordine as and Nm laws minting m
V upon me
building
... ..nsmN'iomndhembyamon purposes. 'ivcs of this cirymcnter
...ficacd property for inspection
(We)sJu agme m caw,indemnify es which may in an w City of Cupertino against '
% liabilides,judgmenu,ensu and expertise which they in any way ecmuc againstaid City
U in consequence of the granting of this permit
APP UNDERST NDS AND WILL C MPLY LTH ALL NON-POINT Issued by: Date
S
ERE LA ON
Z Re-roofs
/Cn tar Dam
HAZARDOUS MATERIALS DI SURE Type of Roof
Will me applicanin
or future wilding occupant at r handle hasomMus material
a defimcd hY the Cupertino Muninp Code.Chapter 9.12,and me Health and Safety
ado,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
O Yes o
Will the applicant or future buil ung areupent sou equipment or dcviws which If a roof is installed without first obtaining an inspection,I agree to remove
emit haardnua.11 conexa imams a recd by me Bay Arca Air Quality Management all new materials for inspection.
Duthie'?
❑Yes u
1 have mad the Imamou5 materials requiremonB under Chapter 6,95 of the Califon,
nut Hcalm 4:Safely Code.Sectors 25505.25533 and 25534.1 undcrsmnd that ifft building
docs not dy have.term'mat it is my mspomthi by to noul'y the aeupans of me
mqui cnlaw hat Ilr etp' tri sane era ea�te.roeee_a.y. Signature of Applicant Date
r or.amodaedagent All roof coverings to be Class"B"or better