03110026 E:,,,�DING
'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT CON1tAC�TOR°,INF,ORMATIO
ADDRESS: CONSTRUCTIVE BUILDING SVC, OMTNO03110026
1iRSNAME: 3937 39TH AVE PERMIT ISSUE DATE
AY CASEBEER MADRID SATCHEL ER 11/05/2003
NE: (510) 531-1175 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
.�0Oz LICENSED CONTRACTOR'S DECLARATION
I u� I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing IOb DCSCrIpt100
with Scniun 9IXYJ)nf Division3nf the 0usincsa�pA� ssin r i g yliccnscis
<.�¢� in full force and cffed -li •I/ REVISION--IN HOUSE USE ONLY
j q? Liccnsc Clas Lic.N
;r� enmmcto ORIG. #03080112/ NO NEW PERMIT ISSUED
ARCHIILCTS DEC
I�V 1 undcrsland my plans shaft he used u public rtcmds
°G t; Licensed Professional
g OWNER-BUILDER DECLARATION
a I 1 hereby affirm that 1 am exempt from the Contractors License Law for the
O O following mason.tilecuun 7131.5,Business and Professions Code:Any city or county
$ which requires a pmmit to construct,alter:improve,demolish,or repair any structure
uix< poor it)its issuance.also requires the applicant forsuch permiuo file a signed statement
FO Nal he is licensed Pursuant to the provisions of the Contractor's Liocnic Law(Chapter 9 Sq. Ft. Floor Area Valuation 0
(commenting with Section 7")of Division J of the Business and Professions Cnde)m
i Nat be is exempt therefrom and the basis for the alleged exemption,Any violation of
Section 7031.5 by any applicant fon Permit subjects the applicant to a civil penalty of 3"0110il-i ca-00 Occupancy Type
not mom than five hundred dollars(3500).
❑I,u owner of the pmpeny,or my employcea with wages as theinolc tompensstion.
Will 40 dm work,and the structure is not imm�ded oroffered for sale(Sec.9044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or through his
n employees,provided that such improvements arc not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner. n
builder will hat the burden of moving that he did not build or improve for purpose of \\
salc)
❑ 1,as owner of the propang am exclusively contracting with licensed contractors in xT
consumer the project(Sec.9044.Business and Professions Cade:)The Cmdracears Li.
cents law dots not apply to an owner of properly who Wilds or improves themmn,and
who contracts for such projects with a comncof(p licensed p roam to the Contractors
License Law.
❑ 1 am exempt under Sec. B At P C for this reason
at Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc of the following declarations:
I haw and will maintain a Ceri fieate of Consent o selbiuum for Worker's Compere
urian,u provided for by Seniors 7700 of the Labor Code,for the Performance of dm
work for which this permit is issued.
o I have and will maintain Workers Compensation Iuunncc,as required by Section
31,Or Ne Labor Cade,for the performance of tint work for which Nis permt is issued,
My Warkc/r'y� ♦C�e 'rtjnn Insure rand Polic��[ryp ,
Cafoer,f� oUn 1Policy Ny✓r
CERTIFICATEOF :XEMITIONFROMWORKERS'
COMPENSATION INSURANCE
(This motion..d not W completed fire Permit is for oro hundred kall.(SIM)
or leu.)
1 candy that in the perf amance of the work for which this permit is issued.I shall not
employ any person in any manner an as of beromc subject to the Workeri Co rrcuation
Law.of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,z forthwith comply with such provisions or this permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
1 toothy affirm that there is a construction lending agency fm the performance or
x the work for which Of,pored is issued(Sec.3M,Civ.C.)
J.1 Q Landers Name
z Lenders Addnss
U Q 1 anify that 1 have read this application and state that the above information is
LyF contract,Iagree to comply with all city and county ordinances and state laws relating to
0V building*L .
by authoria representatives Of this City tocnmrupon the
a ahovcminspection purposes.
( damnify and keep harmless the City of Cupertino against
o-F.t y liabilided expcascs which may in any way&come against said City /
U Z in conaeg of this pafmit. /
^� APPLICD WILL COMPLY WITH/sLL ON-POINT Issued by: Date
SOURC / •�
/ `✓✓✓ Re-roofs
Signewre Appi anti ril"w of Date
H ARDOUS MATERIALS DISCLOSURE Type of Roof
I top applicant of future building Occupant store or handle hamrduus material
u tlefi i by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
do,Section 25532(&)?
❑Yes Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ofuhtobuilding Occupant use equipment ordevices which Ifaroof is,installed without firstobtaining aninspection,Iagree toremove
istricl?h ss defined air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes
I " ousmue alsrcquimmenN under Chapter 6.95 of the Califor.
id.ltoo 6 Sections 255(IS.155JJ and 15534.1 unJcratand Norifthe building
Nos 9d,cu a a t rat Nat h is mY raaponsibility w nnery the recupanl of Ne
req ' ret melpoor wi.aumttnleenop`OfBpa µ Signature of Applicant Date
fit
ow r ori cdagcm (/ tie. All roof coverings to be Class"B" or better