04050102CITY OF CUPERTINO
- ,
BUILDING DIVISION PERMIT
ag�� }}aa�}.� mss° �r
4QA\ IRACTOR5INl'
BUILDING ADDRESS:
R-3 BUILDERS
PERMIT N%4'050102
OWNER'S NAME:
PERMIT ISSUE DATE
MICHICAL WEBB/OAKVLLLE_MAUET5Q3
STONE RD
nc;/1.7/9.nn4
E:
SANITARY NO, CONTROL NO.
(707)748-2255
ARCHITECOENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 t 0 0
LICENSED CONTRAC TOWS DECLARATION
Job Description
by afrom that I am licensed under previsions of Chapter 9 (commencing
1 lovelyo
with Sesmen Taglll) of Division 3 of NC Business and Professions Code. and anlicense is
I n (till force andc �L_
n
REVISION --IN HOUSE USE
a Lic. d
Dm cm..
NO NEW PERMIT ISSUED/ORIG. #03100207
CHITE D'CLARAT N
-u y la Il he cJ Publican Ns
Liccnu Prefcssional
OWNER -BUILDER DECLARATION
1 herchy offrm that 1 em exempt from the Crewmen's 'ceps Lew for the
following moron. (Section 7031.5, Business and Pmfeasioss Code: try or county
which requires a permit to construct, alms, impmw, demollah, at repair any structure
poor to its issuance, aim requires the applicant for such mount to file a signed statement
that he is licensed pursuance the provisions of the Connectors Liccnu Law (Chapter 9
Sq. Ft. Floor Area
Valuation$32
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he Is exempt therefrom and ore basis for the alleged exemption. Any violation of
Seaton 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of
man five hundred dollen
APN Number
Occupancy e
P y TyP
not more ($500).
35908018.00
❑ 1, as owner of the property, or my employees with wages as their sole compenutlon,
will do me .,it. and the structure is not Intended or offend fares, (Sec. 70". Business
and Professions Code: The Contractors Licnou Law does out apply to an owner of
Required Inspections
property who builds or improves thereon. and who does such work himsel f or through his
own employees. provided mat such improvements ..or intended ora(fered foraele, if,
hawever, the building or improvement is sold within one year of rnmpletion. the owner-
builder will have me burtlen of proving that he did not build or improv, for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors in
loas The Contractor's U.
cone
of and Ferproperty
the pmjea (Secapply
to an weerBusi
La wh ds or
and rove law dors not apply to an owner of property who builds or improves thencon, and
who contracts for such pmjecu with a contrsnor(s) licensed pursuant m the Contractors
License
C]1 errsexe exempt under Sec. . B k P C for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby enure under Penally of perjury one of the following declarations:
I have and will maintain aCertilmau of Consent to self-Insum for Worker'sCompen-
as0on, as provided for by Section 37W of the labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code. for m, pm(onesoe, of the work for which this permit is Issued.
MY, curlow's Compensation Insurance enriandrum baram:
- 20 po �
Carries: �jlry No,.
TE—TE-KP�N
FRO ORKERS'
COMPENSATION INSURANCE
(This section n,ed rMlatcamplemd if the permit Is foronc hundred dollars ($103)
or mar.)
I cattily that in the per(ormanec of the work for which this permit it; issued, 1 shall net
employ any person in any manner an as in become subject o the Workers' Comp,nastlon
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: IL after making this Cenlfiem, of Exemption, you should
become subject m the Workers Compensation provisions of the labor Code, you must
fothwlth comply with such provisions or this permit shell be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that mem is a conslrectinn lending agency for the Performance or
the work for which this permit Is issued (Sec. 3097. Co. C.)
Lenders Name
Lenders Address
I cull that 1 have lead this application and sum that me shove information is
-
conCel. 1 agree to comply wit all city and county mo inane and sink laws relating to
building construction, and hereby authorise mprcunmtiana of this city to enter upon the
ehovomantion,d nmpc forimpaction purposes
(We) agree be save. indemnify and keep harmless the City of Cupertino against
costs
nu,casu and expemesw' ay in way ecctu, against said City
in c segonn F me g arcing a( This p it.
AP 'ICA h E ,TAND Y WILL OM Y WITH ALL NON -POINT
Issued by:3 Date
SO UL NS,
Re -roofs
Type of Roof
Sign urc m[A linoomrmmr Dam
HAZARDOUS MATERIALS 69 OSURE
Will the sediment or fume, building Occup lsto .'luodlemeaNmate
mealtimes rial
as defined by the Cupenino Municipal Coda Chep , and the Health and Safely
sssJz(e>7
es Nu
All roofs shall be inspected prior to any roofing material being installed.
ibbict?en
If a roof is installed without first obtaining an inspection, I agree to remove
l the applicant or future building occupant esu equipment or devices which
nes air conumimems as Jerecd by the Bay Ams Air Quality Management
all new materials for inspection.
ea p Pu
oulson
vc read the hasardnusmamrials nu andc hePmr6.95 of the Caliror
Cahor.
COMea
5, 3J en 25570. n crsun6.95 rthc building
I have m L it u my res ibilil I entry me a:cupanl of thets
hmuetpri m seance face flaleo"'anrySignature
t
of Applicant Date
1`O
All roof coverings to be Class "B" or better
uthorized eg,nl Dom
V