03120128CITY OF CUPEWI'INO
BUILDING DIVISION PERMIT
CONTRACTO,R4INFORMATION .
BUILDING ADDRESS:
PERMIT NQ, 3 12 Q 12 8
OWNER'S NAME: -
PERMIT ISSUE DATE
E:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
-
BLDC ELECT PLUMECH
0MB
o 0
LICENSED CONTRACTOR
Job Description
derpoEConsof CON
I hereby affirm this 1 sus lian¢d under provisions of Chapter 9
p
my decncing
withSection 70nB) of Division Berlin, Busircas and ProQainns Cotic. and my liana is
in full Come And effeef
TI--BEAUTY SALON OVALE®
License Class Lie. N
Dale Contractor.
ARCHITECTS DECLARATION
I understand my pans shall be mad a Public records
q
JUN 2 [004
Licensed Prefcsomull
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Commctors License Law for the
yp�q
BUILDING -
following mason. (Section 103 1.5, Business and Professimn Code: Any city or county
which McInnes a Permit to rnrmmm, alter, improve, demolish. or repair any structure
prior in its issuance. also mqutres be applicant for such permit to f Ic a signed statement
that he is Banned Pursuant to the PmWslons of Cmnmeton Usena law(Chapm, 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7I10) of Division 3 of the Business and Professions Cole) or
that he is exempt mcmfrom and the basis for the alleged exemption. Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of
��.o�L�7v7.
1VTZM8r9)
3 y6SV bx��ero (]
Occupancy Type
But mom man raw hundred dollen (1500).
P Y YP
1, as owner of the property, or my employees with wages a their sole eo nfenntion,
will do the work, and Ne structure is not inretbed or offered for ale (SIL. 7044, Business
and Professions Coro: The Contractors License law does net apply to en owner of
Required Inspections
pmpeny who builds m Improves thereon, and who does such work himself or through his
own employees, provided that such improvements an, not intended oroffemil for ale. If.
however, the building or improvement is sold within one year of completion, the owner.
buBder will haw the burden of proving that he did not build or improve for purpose of
Ask.).
1. as owner of Ne import,am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code) The Contractor's Li.
cense law does not apply to an owner of property who builds or improves themon, and
who contracts for such projects with a contractor(s) licenad pursue ono the Comnctors
License Law.
❑lame mLander «. .B&PCf r? spew
O Der
WORK ERSCO E S 1 CLA AT N
I hereby afnmL under pensl f pe one of the lowing deachusta ons:
1 haw and will maintain •Cco fcam of Consent toselhinsure far Worker's Compen.
¢tion, a provided for by Section 3700 of the labor Code. for Ne performarce Of Um
wart for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Code, for dte performance of the work for which this Permit is issued.
My Workers Compensation Insurance carries and Policy number art:
Carrier, Policy No.: _
CERTIFICATEOPP EMPION FROM WORK ERS'
COMPENSATION INSURANCE
(This nation Dad not Mmmpictcd if be pc,miL is foronc hundred dollars ($100)
or leas)
1 certify than in the performance of the work for which this permit is issued. I shall not
employ any Penson in any manner so as In become subject to be Workers ComPeusatlon
LAW. o(Califom .. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Ccisfmne of Exemption, you should
biome subject to the worker's Compewtino provisions of the labor Code, you must
forthwith comply with such provision or this Permit shall Be deemed revnkcd.
CONSTRUCTION LENDING AGENCY
I hc,chy, affirm that Nem is a construction lending agency for the Performance of
dM work fur which Nis permit is issued (Sec. 309E Civ. C.)
Lenders Name
Lender's Address
I cenify that I have mad this application and state Unit he Blow information is
correct. I agree to comply with all city and county ordinances and sum laws relating to
building construction, and hereby Immense mpreanutivss of this city in Inner upon the
shovetmentioned pmpc for iex ecdcunnses pugwas
(WO) agree to saw. indemnify and keep bumlest Ne City Of Cupcnino against
se
liabilities, Judgments, conn and expenses which may in any way acerae against aid City
�.
in consequence of Nc granting of this Permit.
APP C TUN RSTANDS AND WILL COMPLY WITH ALL NON-POINT
TU
Issued by: Dat ,
SOU ,F. I INS. IL
/�
Re-roofs
Dais c of ApplicanUCont{{ for Dam
HA:0 DU ATERIALS DISCLOSURE
Type of Roof
Will the applicant oTlu ore bre ding orstore or handle herardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hcalth and Safety
Cndc, Section 25532(.)7
❑Ye �No
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
Will me applicant or future building «euparal use equipment or devices which
remove
hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection. -
D'sI,
❑ Yes
I have Mad the havrdou� rials oruncruchu doctor Chapter 6.95 of the Cali for.
Dia Hcal" Safety Coda, Sections 25505.25533 and 25534.1 understand but if he Wilding
does not currently haw a tenant, Net it is my responsibility to not ly the occUplot of thI
milli ntsw hist metpdortoissumec accreratcmr
Signature of Applicant Date -
A
All roof coverings to be Class "B" or better
oraothoriredagcm Dam