03040028 CITY OF COPERTINO mlA �-
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
'YVT§9D%4PEVENS CREEK BLVD SCOTT ARCHITECTURAL GRAPHI FSgMITNo'03040028
MT6RM'lHEUS 1275 N. DUTTON AVE. #4 PERMG"S N'7 2/2003
(707) 545-4519 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l o o LICENSED CONTRACTOR'S DECLARATION
�w I hereby affmm that I am lkaaaed r provisions of chapter v(commencing Job Descriptio
�' with Sectio 7 )of Division 3af the Be a and Professions Craigand my been.is
y in full fnrcgc feel. /f
.pz Lima.,.00N Z Lie.a PROJECT ID/DIR. SIG s
i�
DateW O r.
RCHITbar ARATIoN �j t/4 (d
qq `�dcrsta d ae puh� KC„ ;5
G Licensed Pm umna
OWNER-BUILDER DECLARATION
<f 1 hereby affirm that I ant excmpl from me Cent recmr's License Law far the C"
❑O following mason.(Section 703 1.5,Business and Professions Code:Any city ar county
114 which requires a potent to construct alter,improve,demolish,or repair any structure
-ZY prior it)its issuance,also reports,the applicant for such permit mg It a signed statement i
EZp that he is licensed purcuentmthe provisions ofthe Commctur's Lateran lsw(ChapmrY SQ. F 1 a $2�Igl� ion
el- (commencing with Section 7(IBB)of Division 3 of the Business and Professions Ceaejm
RE that he is exempt therefrom and the basis for the alleged exemption.Any violation of �i
Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of 360115FBotvI00 Occupancy Type
net mart than five hundred dollars(5500). V 9'V i�
❑I,a owner of the property,or my employees with wages as their sole compensation,
will do the work.and Ilse SUIRLUm is not intended or offered for sale(Sec.7046.Business 101 - FOUNDP{5�� Id Inspections
pe
and Professions Code:The ns
Crammer License Law docs not apply to an owner of
pronywho builds or improves lhereon,and whodris such work himselforthrough his 103 - UFER
own employees,provided that such Improvements are not intended or offered forsam.If, 104 — REBAR
however.We building or improvement is sold within one year of completion,me owner
builder will have she burden of proving that he did not build or improve for purpose of 105 - ANCHOR BOLTS
sols.).
❑1,as owner of the property,am excluedwly contracting with licensed contractors to 304 - ROUGH ELECTRICAL
construct the project(Sec.7046,Business and Professions Code:)no Contractor's Li. 505 — FINAL ELECTRICAL
cense Law does not apply to an owner of property who Wilds or improve thereon,and
who contacts for such projects wit a eonsnctor(s)licensed pursuant to dm ContrmteYs 514 - FINAL PUBLIC WORKS
License Law.
❑1 am exempt under Sec. ,B&P C for this mann
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby sort.antler penalty of perjury one of Ne following declastians:
ave and will maintain a Cenifo:are o(Consenuo sal6teum far WmkersCompen-
m provided for by Section 3700 of the labor Code,for the performance of the
ar which this permit is issued.
ave and will maintain Worker's Compensation Insurance,a required by Section
3077.1f the labor Code.far Ne performance of the work far which Nia permit is issued.
ar s Competua'on l 6afaneeMearl t y lrcram:
r. Y1 11 ii .:
CERTIFICATE OF EX PI7 FROM WORKER ' 0
COMPENSATION INSURANCE
(This section need not W completed If the permit Is furore hundred dollars($1010
or leu.)
1 certify that in the performance of the work for which this permit is issued.l shall net
employ any person in any mannerist as m became subject to the Workers'Compcnsalion
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:Jr.after making this Cenificate of Exemption,you should
become subject to the Worker's Cempetustion provisions of the Labor Code,you must
� O forthwith comply with such provisions or Nill Mrmluhall W deemed rtvoked.
ti y CONSTRUCTION LENDING AGENCY
I hereby sRrmNat there iso construction lending agency Int the performance of
Y. ti the walk for which this permit is issued(Sec.3097.Co.C.)
A Lender's Name
Add
z Lcndcagrees .
;)Q I certify mat 1 have rued this application and sure Nat me shove infmmrdmi is
F burred..1 agree to comply with all city and county ordinances of and sum laws r upon t to
U above-mentioned proand hereby wthonmmpusers.vas of this City to enter upon the
Q.
above-mentioned gree in averty for emnify an lamp a.
i lY (We)came to save,indemnify and keep yinharmless;the City of l against said
id City
N liabilities judgments.grotsang expenses thispermit. may in any way eccme againstsaid City 6WL2
z in cohsequencc of the Bmming ohhis permit
^" APPLICA U E TANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
SODRQE� IQ S. Nla�.
Re-roofs
Si a Applica dor Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future Wildingm,Capt score or handle Health
material
az dcOncd by the Cupertino iz
l Code,Chapter 9.12,and me Ncalth end Safety
Code,Section 25532(¢)? All roofs shall be inspected prior to any roofing material being installed.
' ❑Yes
Will the applicant orilding mcupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hmardnus sir contaminants deMcd by the Bay Area Air Quality Management all new materials for inspection.
Oixtria?
❑Yes
ihevemadthehamrdo maurialsmquimmenuundcr .Chapmr6.95ofine Califnr
nie Hcalm Sefcty CeM,Sceuww 25N)5,25573 and 25534.1 undcraund NatifIle Wilding
does not I m a tenon Net it o my mspons11111y m nnul'y Ih occupant film
require c W tpnnrmiasuanee fr� Oce acy. Signature of Applicant Date
o arorauthoriutedagent Date All roof coverings to be Class "B" or better