02010005 �,.
. . CITY
DISINO
. -AU[DI c VISIONPERMITC NTRACTOR INFORMATION:
BUILDING ADDRESS: / PERMIT NO,
20658 STEVENS CREEK BLVD GQ'O Ud _-C 02010005
OWNER'S NAME: APPLICATION SUB DATE
ALLEN BEAL 01/02/2002
-� PHONE: SANITARY NO. CONTROL NO.
O OF ARCHITECT/ENGINEER: • / BUILDING PERMIT INFO
g d E ��/� �tel- •/'f RLD ELECT PLUMB MECH
ZO 5 H z LICENSED CONTRACTOR'S DECLARATION Joobb Descri O
I hereby aI irm dne,I ased ua r provisions of Chapter (commencing
w' 11,110 that
�1Ce y,5sy;dProfe11i..ACode. Ad myIcum * NO CONDITIONS
Y E in full fo '-t cC
z w a License class Lic.M O -
a�3 u. Dam Contrecmr a y
CH1TECr 5 DECLARA 0
g I understand my plans shall he used as public recons
in
Licensed Professional _
OWNER-BUILDER DECLARATION
t�s '
M a. 1 hereby affim that l am exempt mnpt from the Ctmr's License Law for the,
f• z a following reason.(Section 7031.5.Business and Professions Code:Any city or county • •7 O Q
F❑ which quires a permit t tinct,alter.imp m
deolish,or mpair any swcwrt
6 m
-pd.,mt 'ss ce,also requires the applicant for such Permit file a signed statement - - -
3 mN i he {I n;cd psis sit tp tR¢ruvi3 ons of the Contactor,L apse Law(Chapter 9 l OI}��0 r a s ValLLatlO
mn
(com ng iNSecto-]000jof D` 'so Sof thea sha,o.nd Plofessians Cade) [0,
or that he is exempt threfrom And the basis for the alleged exemption.Any violation �_ a, ( 1
of Sec don 7031.5byany vpplirdrq fora permit subjects the applicant in civil penalty- LL anC T e
of not more than five hundred dull.,(55W). 10
AP,N " TT't P Y YP
Cl,asownerof the property,u,my emplayesa with wageeas Nei,sole compensation,
will'do'the'walk.and the'vtmcmre is not intended A,ofA.d'for sale(See.]014;' - - -
Business and Professions Code:The Contxcto,s License Law does not apply to an Q 4 R, equired Inspections'
owner of property Who builds or improves thereon,and who does such work himself
AA
o through his own employees.provided that such improvements am not intended or ANCHOR BOLTS _ _. .__ .__
-"o(ksedI r al If,h- thebuilding i s-sold-within on --- _.-__.. . .._ .- . . - _.._ ._-._ ..
gor improvemen r of - - 304 - ROUGH ELECTRICAL"'t'`' ' `O
'completion, he owner builder ill have the harden of proving that he did not build or
improve far purpm..f aid .). _ _
505 - FINAL ELECTRICAL
'Di - lic<nseJco
eroftheproperty,erneKdusrvetycmtveting 'ihntactorsto' - -- - 514 - FINAL PUBLIC WORKS ,. - ----
_a construct the project(Sec.7047,Business and Professions Cade:)The Contractor's
License Law does not apply to an owner of property who builds or improves themon,
and,who contracts-for.such projects with.a contractions)-licensed.pursuant to.thew
Cmmacme,License Law. ,• i i
CI amesemp,under Sec: B&F C for this reason .• ' W1
WORKER'S COMPENSATION DECLARATION
.I hereby affirm under penalty ofpepury:one of the following declarations:
j ❑ l have and will mai main'a Cenificntebf Consent to self-insurt for Worker's
Compenaation, A, provided for by Section 37W of the Labor Code,for the
_ performance of Ne work for which this permit is Issued.
C I have and will maintain Workers Cbmptu smion Insumnce.As required by Section
'3] f the Labor Code,for the performance of the work for which this permit is
.3,uµ ty number Am:
i ed.My Worker's Compcnsai insurance carrier and Poli
- - CSrrier: Palicylvo: G 6S1(�f 7(002 _ 5•...;:,. ::
1 •. t CERTIFICATION'OF EXEMPTION FROM WORKERS . C•s F..••'a J. ,1.
COMPENSATION INSURANCE'"
miWieninn need not be ron leted if the permit is for one hundred dollars ' "- C1 i
I c rt[ythat to the Performanceof theI work far which this permit is issued.) i , i i 1-,a i4.1 -
h ll not employ any person in any manner so as to become subject to the Worker' "
Cot troation Laws of California.Date
-Applicant.' :t
r NOTICE TO'APPLICANT'i If,otter making this Ceni ium of Exemption,you should
Q O 'became subject to the Workers Compensation provisions of the Labor Code,you must
fanhwith comply with such provisions or this Permit shall be deemed mocked.
CONSTRUCTION LENDING AGENCY f i'•I'. ,[ - - --
1 hereby effrn!bat there is a construction lending agency for the Performance L_
i W ► of the work for which this peemh is iisued(Sec:709],Civ.C,)
L
D z Leader.,Addie. - _ ,, li)'.I! .
I certify that I have read this application and state that the above information is
Lia.E,t ;eprrect I a8me to comply with all city,and county ordinances and state laws relating
D.V ;mbuildid, n,wctian,and hereby aothodu mommasuves of this city to enter upon
the above-nu m timed property for inspection purposes.
.f^ 0. I We)agree to sive,indemnify and keep harmless the City of Cupertino ogainat
N City ifics,judgments,costa an expenux which may,in any way acerae against said
zI Cityidrs.j en .I.cAsaa 'ngof iipermie -
.APn, r F ER$T D A\D f�0\IPLY W'ITHALL 60'P01.\ Issued by: V
ate
'gra of Appliq.a?Contracmr I Data Re-roofs '
HAZARDOUSMATERIALS DISCLOSURE '
wit the app) t ,f l 'bis lit g occ pat tore o,handle hrba,o s marmot Type Of Roof --
defoed by rho Cummm CumM pal Cone.Chapter 9.12 writthe Health And Safety
Code C Yen 2557 lal
I. r All roofs shall beinspectedprior to any roofing material being Installed,
_ Will she applicant or fumrt_building c poem use equipment or devices which If a roof is installed without first obtaining an inspection,-I agree to.remove
Arm,huadloo air c ma is Ai defined by he Bay A.Au Qu my Management
District? all new materials for inspection. Applicant under_,[ands,and will comply with .
DYe, ,'. .,..-D,No - all non-point source regulations.., ` -
I hale read thmhax.doas materials requirements under Chapter 6.95 of the
CAlifomia Health&Safety Cade.Sections 25505.25533 and 25534.1 undersand that
-ifthebuildin d esmAcurt ndy h. a Ar m,that it is A)msportsibility r notify the
pant :requineme s hl mus be met prior to issuance of a Cmificaa of
Signature of Applicant Date
— —ff O a All roof coverings to be Class "B" or better
Owner raudiorixd agent- am
.:. . . OFFICE
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