03110148 (2) CITY OF CUPERTINO
BUILDING orvlslon PERMIT CON, R 64OI2yI_NFORMATION '
x. :as
BUILDING ADDRESS: PERMIT NO0 3 11 0 14 8
20640 STEVENS CRF.RK RT,VD
OWNER'S NAME: PERM"MUE DA M
NINSULA BEAUTY 11/25/2003
SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELF.Cf PLUMB MECH
E I�
30o LICENSED CONTRACTOR'S DECLARATION
m 1 herchy affirm hot 1 am of the
Bu under provisions ors Cad¢r 9(commencing Job DCSClIptlOn
F`E wlNSeniop7gM))of Division3oflhe Buxinsnd Professions Codc, dmylicense is
on
in full foto delfen.0 s 7giS14(o SIGN
j Q�? License Cl Li�cMM�p
Ea< Dau`, 'ECI-SDECLARATION t r CONTRACTOR: CALIFORNIA NEON
damn n I beusea as public rccards /✓J��/a�y,����/
)0 /
h C H Licensed Praessm C
g - UILDER DECLARATION . .
�<I0 1 herchy affirm that l am exempt from the Comrenar's License Law for the
O O followingreason.a Permit
t ](131.4 Business and improve,
demolish.
Cade:Any city or county
5$ which requires a Pmmit maimstconstruct,eller,improve,demolish,ar easag any ahuatus
_Zy
that he
iuiensedp rsuasquirts the spinas O theforContractor's
Pcrminoiense L w shapter t
�< ,WtneisBecmsaaPuauammthe pmwismnannbeconuaetur:L�<n:rl.w(chapmry Sq. FL Floor Area
\ aluat"000
e (commencing with Section 7003)of Division 3 of the Business and Professions COJc)or
4 Net he is exempt location.and Ne huis for the alleged exemption.Any violation a(
Section 7031.5 by any applicant for•pandit subjects the aliplixtntto a civil penalty Of APN Number Occupancy Type
not mom Nan Ow hundred r,
P Y YP
❑L as owner of the progeny.or my employees with wages as Heir rote compenution, 35908018 . 00
will do be work,and the swaturt is not intended or offered for sale(Sec.70M.Business
and Professions Code:The Con"clo's License Law does not apply to an owner of Required Inspections
progeny who builds or improves beacon,and who does such work himselfor through his
own employees,provided but such imprmarro care not Intended or offered for sale.It,
however,be building or improvement is said within one year of completion,the Owner.
builder will haw be burden of proving Nat be did not Wild or improve for purpose of
sale.).
❑1,as Owner of be property.am exclusivity contracting with licensed contractors to
canswet be praject(Sec.7314.Business and Professions Code:)The Comneturs Li-
cense Law docs not apply to an owner of property who Wilds or improves Nemon,and
who contacts for such projects with a contractor(s)licensed pursuant to the Contractor'.
enz law.
UV,m exempt under Sec. ,B A P C for this soon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury oro of the following declarations:
I haw and will maintain a Ceniftcme of Consent to self-insure for Warimes Com perr
sation,u provided for by Section 37110 of the Labor Code,for be performance of the
work for which this Permit is issued.
o 1 have and will maintain Worker's Compensation Insurance,u required by Section
3703 of be labor Code,for be Pertormmee of 0s work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Croda: Policy No,: ,
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
ClInsuction need not be completed if Ne Permit is for one hundred dollar(SHU)
or leu.)
1 coolly Nut inyyit pert Of the work f9r which lots permit is---a
seed,I.hell nm
eemploymypersn Inc,mtoont,rs�la hrsply{gbjecuo NC Workeri Compcumion '
FL!i�('�l7
N w CETAPP.CA .oto k
f T7n Ing this CZFE11 te of Exemption,ption,you shuu5
become sub)ect m the Wor urian rovisiom of Nc Labm Code,you mon
Jz forthwith comply with such prnvisiont or this Permit shall be deemed revoked.
z rNrCONSTRUCTION LENDING AGENCY
1 hereby affirm Nat them is continuation lending agency for be performance or
Sa the work fur which this pnmit is issued(Sec.3097.Civ.C.)
13) A Isnders Name
= z Lender's Address
J U I anify Nn 1 have read this application and sum that Ne ebow intermniun ie - (/
(g„ F correct.)agree to comply with all city and county ordinances and sus laws slating s
O V buildingconstruction,proentl hereby amhonP represcnutiwsa(Nis city 10 enter upon thd
W eWw-mentioned I. ertyrove for inspection
mnify an keepJo. .
y,
(We)ag a to cave,indemnify end tech harmless the City O(Cupcnst against S4
fA liabilities,judgments,of ecpatsand of this eswhich may in any way accrue against said City
t.7 z A^Cott CA�NNNfnJJc�JJJ'���eJ 111o11NNc gaiRSmuguftAND WILL COMPLY WITH ALL,NON-POINT Issued by: Date
V
t ZS'�S Re-roofs
Signature of Appfieanl/Co Data
HAZ US b IA DISCLOSURE Type of Roof
Will the applicant car Imus wilding Occupant store or handle hunduus material
u defined by the CupeNno Municipal Code,Chapter 9.12,and the Health and Safety
Code.section 25532(a)1
❑Yea -AN. All roofs shall be inspected prior to any roofing material being installed.
'
Will the applicant or mare building occupant sax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
heusdnus air Conamin...as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? /
❑Yes [�N
I have sad the huardaus mamnalsrequiremenu under Chapter A95 of the Cxlifnr.
nia Health&Safc(y Code,Seedou 25N)5.25533 and 25534.1 unwnund Naif the Wilding
does not cu ha but hmyrcsponihilitywnadlytWaaupantnrth,
ire
requich priorm isabuccor a CcoiBcalc of Occupancy. Signature of Applicant Date
o rarauthori.edas O IL-2-5'v) All roof coverings to be Class "B"or better