04070126CITY OF CUPERTINO
CONTRACTOR INk CSXtMA ON
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PACIFIC GENERAL CONSTRUCTI
PERMIT Nit.
N 04070126
OWNER'S NAME:
PBRMrf I`.SUBDATE
E:
IF
SANITARY OL NO.
ARCHDECf ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
I wroby afRnn that I am licensed coder provisions of Chapter 9 (commencing
Wim Secfu 7001) of Division Sof the Buss. and Professions Co kt..od my license is
Lise.class `rr"` Lic.A
-REVISION--STRUCTURAL REV.
n
Dam cMmne
NO NEW PERMIT ISSUED/ORIG. 03100011
$
ARCHnECI' DECLARATION
I understand my plans shall he used As public records
DEFERRED ELECT. /MECH. 404060206
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby allism that I am exempt from be Contractors License Law for the
following r.aan. (Section 7031.5, Business and Professions Code: Any city or county
Which requires a Permit to construct. almf, Improw. demolish, er repair any elmcWre
prior in its issuance, also mquim, the applicant forMeh permit to file a signed summent
Sq. Ft. Floor Area
Valuation
that w is licensed purauant m me provisioarf lw CwMm1 '1 Llanse LAW(Chapmr 9
(commencing wish Sec0on 7000) of Division J of ow Busin ussand Profession Code) or
that he Is eumpt Iwmfrom and One basis for me alleged cumptlon. Any v1.1.1 o. of
APN Number
Occupancy Type
Section 7031.5 by any applicant fora permitsubjectsthe appllnnl to a civil penally of
not mom than am hundred dollars ($500).
1, as owner of the property, or my employees with "gas At their sole eompar adon.
36906009.00 Required Inspections
will do tie Work and the structure is not intended oraRaad for Aside (Sm. 7044. Buslnass
And Embargo... Code: The Conuscu,s Liana Law does not apply m an owner of
property who builds m improve. Hereon, and who does Ouch work himul f or through his
own employ es. provided thatsuch improsemeou are notinunded moRered boggle. If,
however. me building or Improvement is sold within one you of completion. be owner.
builder will ban Use burden of proving that w did not build or improw for purpose of
am.).
1, a Manor of the property, am uclusiwiy contracting with licensed comnnon to
$._
Codes) Thews the ms's lid
(Sec. 7044, Business and ny who
M used the does and
cense Law dose not apply je an owner of property who geoids or improve
s,\
,v^
COMeM
whocontractsLa. for Ouch projects with a conlnner(0) Ilanud pursuant m the Contnetofs
License AW.
❑Inn taemN on `�; B&PCfor this won
ow e- o//u"'D
'
WORKER'S COMPENSATION DECLAN
I hereby affirm underpenaltyorped., one of bte owing declaraloa:
Mn and will mainuin •Ceeifam of Conunl m ulf-insure fm WorkeesCompen-
toon, u provided for by Snodw 3700 of the Law, Code, for the performance of the
work for which shin permit is issued.
❑ I haw. and will maintain Workers Compensation Insurance, as required by Section
3700 of Ne Labor Code, for the performance of the work for which min permit Is Issued.
My Workers Compensation Insumnce carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPOON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleed Bring permit is return hundred dollars (SIM)
orI o.)
1 cenify that in the performance of the work for which this permit is laud. I shall not
employ any pcnon in any muncrw As At become subject to tw Worktti Compensation
LAW, of Calffomia. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
become subject to No Worker'. Compensation pmviduns of be IAwr Coate, you must
forthwith comply with such provision or Nis Permit shall to deemed revoked.
CONSTRUCTION LENDING AGENCY
1 sur ton Nat mem is agency for the performance of
s ed (m . 30lending
whatT
' the work for which this permit Is fused (Sec. J097, Civ. C.)
Lender's Nem.
/
InndeYI Add.
I agree that 1 pan mad this application and tum con Inc, own information mnatiun to
C/J/
and and sou law mining to
uildin 1 agree ct comply Wim all city and county nualwa
Of
and hereby umasms. tivca of role city censer upon the
forimpmhon
altonngeotioned mcrlyon,
eww- tion Property for impaction an
I ha
keep a be city or Cupertino Against
(We)agmeto ave. indemnifyandkeep
(W re
i liabilitiq.Judgmenu.mw adeepemu which mryin any wayamuc agatmt aid City
.yin
in consequence of to granting of this permit.
I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL/NON-
Issued by: Dale
SOURCER S
-
Re-roofs
Type Of Roof
S' beof pplicanbConuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant nom or handle harudous material
defined by me Cupenino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Secuon M32(a)? y
❑Yes Iy 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 remove
Will Iw applicant or future building Omupan use equipment or dcvi= which
it havmmmus air conumoun s u defined by the Bay Area Air Quality Management
11
all new materials for inspection.
sic@
OJ-
'
❑Yes
1 have mad be heardous.=flat, mquiremcn s undo, Charter 6.95 or the COlifm-
.is Health k Safety Code, ScNes 75505,25533 and 25534.1 understand Ihu Box, building
does not currently haw a gnat. that it u my rupomibility In notify ole oaupent or be
mquim nu wh' hon At tomo prior to issuaaof a C.mrc.w of Occupancy.
Signature of Applicant Date
0�
All roof coverings to be Class "B" or better
boner or lunhorbecd agent Data