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CITY OF CUPERTINO�'
RMA f,
BUILDING DIVISION PERMIT
T CONTRACTOR INF JON
Bu LDING ADDRESS:
PINN BROTHERS CONSTRUCTIO
5-fim"'D' 05080178
Its NAME:
1
PE'RFO7ISSl1E DATE
P BROTHERS1475
2006
NE:
SANITARY N0, CONTROL NO.
408)252-9131
ARCHMICTIENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
D O O 0
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
I M eby of affirm that 1 am licensed unlet provisions of Chapter 9 (commencing
with Section 700B of Division 3 of the Business and Professions Code. and my license is
in full face antl eRea
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NEW CONDO -919 I
Liaenx clew Lm.«
Da¢ (� ConRecxr T. rw.s=�o'ffw-A.f t
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ARCHITECT'S DECLAR— F7 Fo
s
1 understand my plans shall o used ea public retards
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby a1Bm that I am exempt from the Contnemrs License Law for the
following mason. (Section 703 1.5, Business and Profentiou Code: Any city or county
which requires a permit to ennd nsc4 after. improv, demolm, or mpair any Mrumurc
$197006
PA. an its kssunce, also vequims the applicant for such Permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed Punuanuo the provinces of the Conuxmr's Ltcenx Law (Chapter 9
Sq.
(commencing with Section 7020) of Division 3 of doe Business and Professions Code)or
that he Is exempt therefrom and the bub for the alleged exemption Any violation of
Occupancy Type
Section 7031.5 by MY app0um for a permit mbjccu the applicant in a civil penalty ofr•
not mom than Ove hundred dollars (5300).
❑ T, as owner or the property, Or my employees with wages u their rote compenwtion,
Required Inspections '
will do the work, and Ne structure is not intended or offered for 36C 7014, Business
and Plains Ions Code: The Conmcmr's License law does eat apply in an owner of
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property who builds or improves themon, and who does such wek himself or through his
own employees, provided Nm such improvements me not intended or offered for ale. If.
however, the Wilding or improvement Is sold within one year of completion, the owuer-
Wilder will have the Wrden of proving than be did not Mid or improve for Purpose of
wen.).
❑ 1. as eamer of the property on esclusively contracting with licensed mntracmn in
conalrecl the parka (Sec. 7011, Bu1me s and Profession Cade:) The Contracrcrs Lt.
« nae Taw docs not apply in an awns of property who Wilds or impress daemon. and
who comneu for such projects with aconuaemr(U licensed pursuant in Om Commerce,
License Law.
❑ 1 am attempt under See. . B & P C for this moon
er Date
WORKER'S COMPENSATION DECLARATION
I hereby aRm under penally of perjury one of the following declarations:
I have and will maintain a CenlOwte of Consent to self -insure (e WavkeM1 Compcn.
tiIan. an provided for by Section 3700 of the labor Cade, for the performance of the
work for which this permit is issued
❑ 1 have and will maintain Wmkeea Compensation Insurance, as required by Section
3700 of the laor Code. for the performance of the work for which this permit is issued.
My WaheeeCompenaMlam Insurance envier and Policy psi W rlam O I�
Cartier: t—C.-V Policy No.A
CERTIFICATE OF EXEMPTION FROM WORKERS'
- COMPENSATION INSURANCE
Innis serous im d not xcomplmed If the remelt in forme hundrctl dollen ($100)
of less.)
I Mnify Not in Ne performance of Ne work for which Nis Permit is intend. I shall not
employ any person in try mannerso u to become subject to the Warkeri Compewtion
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Cer iOcate of Exemption, you should
become subject to the Workers Compensation provisions of the Labe Code, you most
forthwith comply with such pmvistou or this permit shall be deemed revaked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm dao them is a construction lending agency for the performance of
the work for which this permit Is issued (sec. 3097. Gtv. G.)
'
Landers Name
Lender's Address
I ceAfy that i haw read this application and state Nn the Move information 11
toren. I agree to comply with all city aha county ordinances and sum law, mining to
Wilding construction, and hereby authorise rtprcxnmiws of this city in enter upon the
sow-mentionedp ny rue inspection purposes.
(We) agree taw. indcmni d keep harmku the City of Cupertino against
liabhubujudgme, ,eossand on which may to anyway acerae agaiutwid City
in conxqurncco cgnntin (this roil.
APPLICANT ST DS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date % =
SOURCERE A N
Re -roofs
Type of Roof
—
Signaturto A cwVCon r Dam
HAZARDOU MATERIALS DISCLOSURE
Will Ne applicant or futue Wilding Occupant More m hauam
handle hNuus aenad
ented by tine Cupertino Municipal Code. Chapter 9.11. and dae Health and Safety
Section 13531(.)7
❑YesWill
All roofs shall be inspected prior to any roofing material being installed.
a roof is Installed without first obtaining an inspection, I agree to remove
the applicant or future Wilding Occupant use equipment or deviw whichIf
hawardou air wnuminws w cd by the Bry Arta Air Qualify Management
all new materials for inspection.
❑Yes NuThew
1&96,6jxoAl%d'
the hasardo are lebmyulmmenu underChapter6.95 of the Gli(oo-Health@S
IyCodc, ons 13 5.35533wd13331.1undcnlantlthatifdae Wilding
not cu dy haw nut4 N Itlsmymponaibilitywnotifytheawuptofthe
lmmen 'c m Wmet ormiasumccoraCmdnwearacupatcy.
Signature of Applicant Date
O
All roof coverings to be Class "B" or better C%
a Date
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