01030156 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: PERMIT NO.
23100 VIA ESPLENDOR # 43 01030156
03/28/2001
IV
PHONE: SANITARY NO. CONTROLNO.
p O z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
t,-u— BLDG ELECT PLUMB MECH
�a
LICENSED CONTRACTOR'S DECLARATION
O Z 4 E 1 here. firm that 1 am lim,sed under f Cha ler 9 r,momencin Job Description
hereby Provisions p g
°°„_� with Section mod,ffxc,,Division meazandProa„ion.co . mmyuan CONVERT AREA UNDER DECK INTO
=x s sc L m fall rlass <rr STORAGE ROOM (2 0 5 SQ. FT. )
z s 6 License Class Lic.a
3 H Data Contractor
ARCHITECT'S DECLARATION
h o-- ; I understand my plans shall he u.ad as public records
ex
�r
i S p O L.Mnmd Professional
LL OWNER-BUILDER DECLARATION
I 1 hereby affimn that 1 am exempt from the Contractor's License Law for the
following reason,(Section]NLS,Business and Pror..ions Cods:Any city or mum,
iso
which re,mirev.pe nmcbri alle,unloose.d,mi M,virravabacho,
uta, Pr tt 'I y II ppl' tl hl Il fl '.F ditnel _
$ p
«- matnq ntin fedi rs t. n p nl<L sol lin I (Cliioro Cur 9 S Ft. Floor Area 156-V nation
(commhe Ing wed Sfcuonom and
feaBusnessaed Pq,fAnyvi Code) _ stn'.
or that he is exempt Iherc&con and the basis for the,i,,hJ..11,a ten.Any violation -
of S«tion]U3 LS by any applicant for a permit wbjens the applicant m a civil penally
of..,more Than five hundred dollars(S50i umber r Occupancy Type
Dl.as ownerofthe property,or myemployees with wagcsas their wale compensation, ri r _
will do the work.and the structure is not intended or offered for sale(Sec.7044.
Business had'Poi....Its Cod, Ina Cmnmctor's Lian.e Law J.es not apply to an Required Inspections
owoc
r of property Who build,or impmves them..,anJ who d e,such work himself
or through his own employees,provided that such sarin mans within
not amended or
comple for sale ((however, will
l have
em rs sold welt n mm d f -
gorinproven year. .,
.prove for the owner-builder will have the burden of proving that he dad not Wild m
improve far puryuu of sale.). I
as owner f the Ni - I eiy c vacrn8 with 1 ttnsal t con to t --
convoract theProject(S ]BM R d P f:. cr :1 The Connector's
I
License Lars,ch.,not pplyt owner off,oi who bull 'cop :thereon
and who commucts for h projects wnh a commeamrs)licensed pursuant to the __. .._. ...
Contractors LicansicLa .
- C
Owner WORKER'S COMPENSATI DEC RATION
runhiv Mason / /�[ '�• l'
i hereby affirm i ndar ptlior ofperjury unc of the follnwit8 Jedaratiuns: �//J/��\
❑ 1 have and will maintain a Certificate of Consent to self-insure for Workers /
Compensation, os provided for by Section 3700 of the Labor Code, for the
” _- performance of the work for which this permit is issued. ,.
D I have and will maintain Worker<Gimpenwtiori Insurende,as required by Section
37W of the Libor Code.for the perfomuncc of the work for which this permit is
n.wed'My Workers C,mp<nsmion Imuran[,carrier and Policy number are
.. ... . . .. .. . . ..._._ -. _ __.. .. .. ..... __..._.....-. _.._._...-.._.. ..- __
Carrier. ..✓ r' :I''t'• Policy No.: -
,l;[ CERTIFICATION Or EXEMPTION FROM WORKERS'(
', ,• , . COMPENSATION INSURANCE—,
(This ui'tlnn nee)nal be unnpincJ R the p:rmit is for one M1unJrcJ dollars -
fS I W I or Icss.)
I' m7y,that in the performance of the work for soh h m:p I is issued,I
shall not eirinjil8y any person In any manner so as to became.ubten to the Workers
Dam
:Applicant
Compensmian Lvwi of GJifolnlu.
NOTICE TO APPLICANT:If:after making this Cenificae or Exemption,you should ”
hecdmpe
me subject to the Wnrkcr's Cnnsalm.pbivkde,in r,of the Labor Coyou must
O OforthwitheomPlywithsuchprovisionsorthisPermit<hallhedeemedmvoked.
CONSTRUCTION LENDING AGENCY "
1 hemhy of inn that there is a construction lending agency for the performance -
Ls7 ^ of the work for which his
Name thi.i permit is issue)(Sec.3097.Civ.C.1
a? der's Name .... .... _. . .. _ .. _
L Lens —
. �.z t<ndcr
t••)-F- .1 certify that I have read this appllcd ou a,J,ate(Fat the valve lawsoelon
tar-E. correct.I agree w comply with all city and eoepr onlinzmss and state lawsarhong
-[� nth o g ti t Ih hys th z P tf' ttM1': 'y to upon
A. the Wmentioned_ s pend f pactIsmaili
- j �•S
G Ove)agree t s e indemnify J, chat yi IM1 City fC pen against
fn liab I j dg h. ......J<xp<ere b<I u:ry ,any y ,gaunt r iA
Citym nmscyue&s of the gmming of thsperm 1.
APPLICANT UNDERSTA�' WILL COMPLY WITH ALLNON-POINT Issued b Date
SOURCE REGULAR . 1 ' Y'
1. 6�Zq1
.marct Ai3pincam ommanr Dele Re-roofs
r HAZARDOUS MATERIALS DISCLOSURE
Aid"rhe applicant or hi building«apant score or humne hvardous material Type of Roofas de ined by,the CupenlnoMome pal Core.Chupmr 9.12,and the Hcalm and Safety -
Code.Section25532(x)'!.•• L :; , )' : ,- k
t All.roofS.shall be inspected prior to any roofing-material being-installed.-
Will
eing installed._ ... . _
• sVll ar,air,applicant m<W buildingecabalism M. n t d garam If a roof is installed without first obtaining an inspection, I agree'to remove
III h tardus aplicant r future
nts udefnd by'he uArcaA Qaltyev,ce,which
n<t� all new materials for inspection. Applicant understands and,will comply with
all non-point source regulations. ;•�,.
1 base read the hazardous mvteri.als rrquiren em,nnJer Chapter 6.95 of the
California Health&Safety Cod,Sections 15585:3533 and 25531 1 undersand that
if the building does not currently have a am.a.tbm it is my responsibility to notify the
'occupant of the requirements which must be met prior to issuance of a Certificate of
OccupatsY.
Signature of Applicant Date
1 °
wor oat « eat All roof coverings to be Class `B" or better '
n<r Date
_ . . i OFFICE ..