04030263 4OWNER'S
CUPERTINO �'� ^'< ` " ' �,7
NG DIVISION PERMIT ONTRACTQR UtMAT,IO1V
�,:
DRESS: DAVID VALVERDE PERMIT N0.04030263
E: PERMIT ISSUE DATE
SANITARY V I OL NO,
ARCHITELT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
v00 LICENSED CONTRACTOR'S DECLARATION - - 'Job De5Cf1pI100
1 Wroby aMrm Nat 1 am licensed under previsions of Chapter 9(commencing
with Smile.7")Of Division S of the Business and Professions CodC and my license is
<� I.roil farce aod.H.m -REVISION-- N HOUSE USE ONLY -
7 Z License Class Lit.X
Dare Cmucamer MIT ISSUED/ORIG. #04020155
ARCHITECTS DECLARATION
�i I understand my plans shall W used as public records
Ca,V
3 G Licensed Professional
3 OWNER-BUILDER DECLARATION
iI 1 hereby affirm that I am exempt from Cu Contractor's License Law for the
i ao following mason.(Section 7031.5,Business and Pmfo sions Cole:Any city or county
X22 g 2 which requires a permit to construct,alkr,improve,demolish,or repair any atmm
etu
to
prior to its issuance,also requires the applicant for such permit to file a signed statement
� < that W is licensed pursuant to the previslan of the Comecor's Lkcnm Law(Chapter 9 Sq.Ft.Floor Area Valuation so
an C (commencing with Section70(IU)of Division 3 of the Business and Professions Code)or
5$ that he is exempt Ihmefrom and the basis for the alleged exemption.Any violation of
Secdon 7831.5 by any applicant for a permit subjects the applicant m a Civil penalty of APN Number Occupancy Type
oat more than five hundred dollars(5500).
,as ma.of Ne property,or myemployees with wages as Weirsole compenwtlon, 35703035 •.00
wdldo the work and da munum is But intended oroffemul formic(Sec.7044,Business
and Professions Code:The Contractors License Law does nor apply in an owner of Required Inspections
progenywho builds or improves thereon.andwhodoesauch workhim olforthrough his
own employees.provided that such improvements am not intended oroRemet foreala IL
howcwoq the building or improvement is sold wWrin ane yourof cemplefien.Ne awner-
builder will love W burden of proving Nat he did not Wild or Improve for purpose of
tale,),
1,u owner of the property,,B sines and contracting with )Theed common i-
mmswd to project(Sec.o an Business and Professions Cade:)The CmmckYs d
cense law coca not apply je an with
a of property who Wads or improve Contra,and V
who contracts for such pmje<LL wiNacanuactor(a)Burned pursuant to We Conuettofe -\
(..Im Law. '
am exempt under Sec. .B&P C far Nis recon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificatea0of Consent to self-insure for Workers Compcn-
son,as proW
vided for by Secdon 3700 of Be Lar Code,for the perform...of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insprance,as required by Section
y37 f the labor Code,for the perform. of the work for which this permit is LLsued.
M Crane ore nation senna 'e and Policy number
n PION N
ERT IC OF P170N FR O
O ERS'
COMPENSATION INSURAN E
(Tris R:nime need not W Completed If be permit is for one hundred dollars f$100)
Of leen)
1 certify Net in We perfmmaoce of the work for which this permit is inured,l shall not
employ any person in any mannerm as k become subject in tW Workers'Compenss ion
Laws of California.Doc
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in We Workers Compensation provisions of We labor Crock.you must
Z forthwith comply with such previsions or this permit shall W deemed mvaked.
OCONSTRUCTION LENDING AGENCY
Fe I hereby&Mm that there is a construction[ending agency for the performance of
Clsthe work for which this permit is issued(Sec.3097.Civ.C.)
WLoader's Nam.
�,7-i Lcnderb Address
U 0 1 certify that 1 have met this application and state that We shove information is
g4 correct.I agree to comply with all city and county ordinanme and auk laws relating k
0 Wildingcanawction.and hereby auborim represenutives of this city to curer upon the
r IUlt about-mentioned property for inspection purpose.
(WO)agree to save,indemnify and keep Wooden the City of Cupertino against
ti y
liabilities.Judgments,costs and expenses which may in any way memc against and City
U Z in consequence of We granting of this Permit.
•+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ^ UL "ONS.
Re-roofs
i adurcol'Applicerucilouractor olopm
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will sec applicant ar future Wilding occupant nom mhandlc Imendous eau cid
tdefined by the Cupertino Municipal Cade.Chapter 9.11,and the Health and Safety
d..Section15531(a)7 �a All roofs shall be inspected prior to any roofing material being installed.
❑Yes %(.Will the applicant or future Wilding occupant use equipment or devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
it h4vardous air contaminants n defined by the Bay Area Air Quality Management all new materials for inspection.
trict?❑YesI haw mW the lina Boons malerialsmqircments underChap or 6.95 ofNe Califor-
Heslth&SafclyCode,Secdon15505.15533md25534.1undemmduatifthe Wilding
s not currently have a onane that it is in roe ibii bit m no01'y aceupmt of the
mquimmenta which must el poor saumcc e ,cWficauof p Signature of Applicant Date
own aalhz; agent All roof coverings to be Class "B"or better