02110055 CITY OF CUPERTINO "�» -
BUILDING[)]VISION PERMIT *CONTRACTOR INFORMATION:
BUl 1 .RE. TONEBRID_GE ST SAIN JOAN S Pmeln-N0.2110055
OW07ASINNAEJOAN S APPLICATIDIIsPU T 2002
.40NE: SANITARY NO. CONTROL.NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MBCII
I� 0
w00 LICIiNSED CONTRACTOR'S DECLARATION C�yy�
rc�F I wish,affirm mal l am licensed under pmvilwas of Chapter 9(commencing ADD VOLTAGECANtob'I O" 'iC1 NEN CEILING
`5�u with Seelion]m)of Division 3 of the Business and Professions Conte,and my license is
in full force and affect.
t2K License Class Lia M
Naa W Dam TS Contractor
ARCIII Co DECLARATION r
gay I understand my plans shall the used as puhlic records L�^
apwV �J
w3 a� Licensed Prntossamod APR
0, OWNER-BUILDHR DECLARATION 1 2003
<� I hereby all that I am exempt from the Cmm�cmr.s License Law(or the - $200
ua a❑C following reason.(Section 7031.5,Business and Prnfcasinm Code:Any city or county
s�$ which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its immance.alm requires mcapplicantforsuch Permit to rile asigned statement 01 11a
�o
ESC thalhe is licensed pursuant sea the provisionsofthe Cuntmamr's License Law(Chapten9 39g2Et3IEl®o�A@0 sJiVU Valuation
K t—$ (commencing with Section 7000)of Division 3 ofihe Business and Professions Code)(it
coy Nal he is exempt(henchman and the basis for the alleged exemption.Any violation of
Secured 7031.5 by any applicant for a permit subjects the applicant to a civil penally of PNN Occupancy C
not mom man firs hundred dinars(S501)). 501 - FINAL ELECT) CAL ENERGYp yTyp
❑I,as owner of the propeny,or my employees with wages as their snit compensation,
will do me work,and Ne swmure is not intended or offered for sale(Sec.7044,Business
and Productions Code:The Contractor's License Law does not apply m an Owner of equtre nspec[ions
property,who builds or improves mention,and who does such work himself or through his
own employees,provided that such improvements am not intended or Meted for aide.If.
however,me hui lding or improvement is sold within one year of completion,me owner-
builder will have the burden of proving mal he did not build or improve for purpose of
aale.).
❑1,as owner of the property,am exclusively contracting with licensed cunlnnnrs m
consumer the project(Sec.7(W,Business and Professions Code:)The Conlracmr's Li
wrow Law does not apply to an owner of pmpetty who builds or improves mamma,and
who contracts for such pourers with a comractm(s)licensed pursuant b)the Contractor's
c Law.
I am exempt under Sec. 1 BCC%Ihis�eason
WO < COM ENSA ATI(yfV/
I here y affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent rural Norma,for Worker's Compere
Whom,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Werler's Compensation Instudow,as required by Section
3101 o(tbe Labor Code,for me perfntmance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy nnmher art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fon one hundred dollars($10)
er less.)
1 certify mal in Iho per r nonce of,hc work for which this permit is issued.I shall out
employ any person t yni nes n sunject to me Workers Compensation
La sur Cel r 'a. are
A c It a4Ls
NOT(a TO PPLICAM':IL afte mT(Ihis Cenifcate of Exemption,you should
I ecome subje t m the WorkcrS Cempenaation pmvisiens of the IaMa Code,you must
OO forthwith comply with such previsions or this Permit shall deemed revoked.
z "' CONSTRUCTION LENDING AGENCY
[-� I hereby affirm that there is a construction lending agency lin thepMnrmance of
Q'. a
fire for this (Sec.lly37.Civ.C.) ^.
UJ Lender's Name L
� ,Z Lender's Add.
(�Q 1 certify that I ban mad this application and sate that me above intimation is
Fcomer.I agree to comply with all city and county ordinances and state laws relating
Q V building construction,and hereby autbmisc representatives of this city to enter upon the .(-5/
w above-mtiminntiJ pmpcny for inspCcfinn purpn¢s. V
C (We)agree In save,indcmni fy and keep harmless the City of Cupmino against /
Hy liabilities,judgmenu,costs and expenses which may in any way secure against said City r
V z Inconsequence NDTFRSTA of this permit, t qZ ,
r—' APP CANT UNDF.RSTA SAN WILL COMPLY WITH AL1.NON-POINT Issued by: Date d l///
SO EREGULAT ONS. rA
14� Re-roofs
nal Of PP,imu nmracior Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
I])the applicant or future building occupant store er handle hamrdous material
as defined by IM Capenin,,Municipal Code,Chapter 9.12,and the Health and Safety
Code,sreyes 25532(x11 All roofs shall be inspected prior to an roofing material bei[) installed.
❑Tea l�jrvn P P Y g g
cow sen appbeam nr ml rr building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
eon bavardnas air enntaminam.s Is defined try the Bay Area Air Quality Managemcm all new materials for inspection.
Dll Gs
❑Yea
I have read me M1ararJnux ials rcgniremenls under Chapmrfi.95OI me Coliba.
ria IleadhX SafetyCnlc.Sectinna255015 25533 and 25534.1 umknand mal i(the building
u
dors no mve olly haa uman that it my mi,souihility to nobly me oOcupim of me
require csw 'chinslheat prion ssmancenl'aCenilicaof G, Y.
Signature OfApplicant Date
net r uthnriscd agcm Dam Alf roof coverings to be Class "13 or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent, spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work 7
If B or C is checked,complete 2 or 3 below. U
6
2. A state licensed contractor will be hired to do: NOV 0 2002 - i
A. _ All of the work By B. _ A portion of the work(complete section belo )
Contractor Address/City Phone # State License # Type of work to
be performed
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perforin all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
..................................................................................................................................................................................:..
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
r 7
Property Owner's Signature !/ �te:
Job Addre,/� ( / .� Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.