04050038CITY OF CUPESION
CON IUCTOR TNWI MATION:
BUILDINGDIVISION PERMIT
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Bl11LDING ADDRESS:
WILLIAM NANCE
PERMITNO04050038
18965 TILSON AVE
OWNER'S NAME:
PERMIT ISSUE DATE
18965 TILSON AVE
06/09/2004
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SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Not 1 am licensed under provisi... f Chapter 9 (commencing
with Scene. 70fal). Division 3 ofthe Business end Professions Colle,and my license isj�p
�6d
NAL
full fore,andeffem.
DEMO �JAEo
ED
License Class We. g
Da¢ Canlsacwr
ARCHITECTS DECLARATION
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JUL 6
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I understand my plans shell W used a public cords
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Licensed Professional
OWNER-BUILDER DECLARATION
pg�
SU'L09
I hereby affirm that I em exempt from the Contracmr'a License Law for the
tj(
following mason. (Section 7031.5, Business and Professions Code: Any city .,county
which requires a permit to construct, shot, impmw, demolish, or repair any nmctum
prior to its issuance, also requires the applicant forsuch Permit to Ole a signed statement
that he is licensed pursuant to the provisions of dm Contractor's License law(Chapmr9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of the Business and Professions Cole) or
Nat he Is exempt m,refrom and the basis for the alleged! exemption. Any violation of
@
Occupancy Type
Section 7031.5 by airy applicant for s permit subjects the applicant to a civil penalty of
not mom Wen Ove hundred della. (55110).
❑ 1, m owner of Ne property, an my employees with wages w Weir sole compensation,
Required Inspections
will do the work and the structure is norimended oroffered thrash, (Sec. 7044, Business
and Profesrions Code: The Cem comes License Law does oat apply In an owner of
property who builds or improves the.en, end who does such wmk himself or through his
own employees, provided thatsuch imp awments are not Intended moRered fmsale. If,
however, me building or improwment is said within one year of completion, the owner-
builder will haw We burden of proving that he did not Wild or improv for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and profestions Code:) The Contncmr's Li.
come Law does not apply to an owner of property who Wilda or Improves thereon, and
who contract, for such projects with a contractor(s) licensed purnamann to the ContramoFa
ase Law.
I. exempt un der S ,B&PC for Unixmoon
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WORKER'S COMPENSATION DECLA ION
I hotels, affirm under perafy of p do, one of We following declarations:
haw and will maintain a Certilmate of Consent to self-insure for Worker's Compcn-
sation, as provided for by Section 3700 of the Lather Code, for me performance of the
work for which this permit is issued.
❑ 1 haw and will maintain Worker's Compensation Insurance, as required by Section
3700 of We labor Code, for the performance of the work for which this permit is issued
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My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(r ds section need meWcmnpleted if the permh is for one hundred dollen (51 W)
or less.)
I certify that in the performance of the work for which this permit is issued. l shall not
employ any person in any mannerso as to become subject to the Workers' Compensa0on
Laws of California. Dam
Applicant
NOTICE TO APPLICANT:If, a0r, making this CeniEcaw of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
forthwith comply with such provisions or this permli shall be deemed rewked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Wal Nem is a conmuourt lending agency for me Pointers.. of
mh work fur which Nis permit Is issued (Sec. 3097, Civ. C.)
Lender's Name
Leader's Adder..
I certify that I haw mad this application and sure that the above information is
correct I agree m comply with all city and county ordinances and sum laws relating to
building construction. and hereby authorise mpresemati es of this city to enter upon the
aWw-ommioned property for inspection purposes.
-
(We) agree to once, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, costa and expenses which may in my way &come against mid City
in consequence of me granting of this permit. TH W&
POINT UNDERSTANDS AND WILL COMPLY WIALL
Issued by: Date
S CEREGULATIONS.
Re-roofs
igmturc efApplm Dc
An.n_ZARDOUS
Htae
MATERIALS DISCLOSURE
Type Of Roof
Will the applicant or future Wilding occupantsmrc or handle bmudous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
ode, Section 25532(&)?
All roofs shall be inspected to any roofing material being installed.
❑Yes No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or wet building occupant use equipment or devices which
t haaemous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ,
I havemadmehao us materials requirements under Chapter 6.95 ofthe Califon
nia Health&SeetyCodc,Secuom2SW5,25533md25534.1un&m=dWatifdm building
does not currently how a tenant Net it is my responsibility to noul'y the occupant of the
mqulmmen whi, mnatn,metpriartaiaaamhearaamneatear h an�
Signature of Applicant Date
All roof coverings to be Class "B" or better
weer or authonxed agent Dam