04010133 i
Y OF CUPERTINOBUILDING DIVISION PERMIT CONTRACTnWIIVI+'CI�I�IATIOI�tING ADDRESS: T H GENERAL CONSTRUCTION C PEBMITN"b4010133
. 88 WHEAT= DR
R'S NAME: - PERMR ISSUE DATE
E: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: _ BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0
opo LICENSED CONIAACTOR'SDEConsof CON Job Description
I hereby affirm that I am limned under provisions ofChapterCook, 9(commencing P
with Section] puf Divi on3 of NC Businusapy✓imfcssinnsC do and my license is
in full fore effect. s lM
X44 Lmeamc le.g Z REVISION--IN HOUSE USE ONLY
;moo Dale —o cantraatar NO NEW PERMIT ISSUED/ORIG. #03020051
e¢¢ ARC71=1 \RATION
g W I understand my plans shall he uscu p hit.retard. -
a
l' v1-i Licensed Proficamnt -
OWNER-BUILDER DECLARATION
<I 1 hereby affirm that I am exempt from the Contractor's License Law for the
i 000 following reason.(Section 7031.5,Business and Professions Code:Any city or county
e m which requires a permit to construct,alter,improve,demolish,Or repair any structure -
prior to its issuance.also requires he applicant for such Permit to Bic a signed statement
'££sp
that he is licensed pursuant to Ne provision of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuatil107
yt- (commencing with Section 7")of Division 3 of the Business and Prafessions Cutlet or
y $ that he is exempt Nemfrom and 0m basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil candly of APN Number
not...dam file hundred dollars(M). Occupancy TyPe
❑I.as owner oftheproperty,or my employees with wages a their sole compensation, 31628001 . 00
will do the work.end the ancwre is not intended oroffered forsaic(Sec.7044,Business
and ProfessionsCode:The Contractor's Lice.law Coos not apply to an owner of - Required Inspections
property who builds or improves thereon,end who does such work himself or through his
own employees,provided that such improvements are not intended oroRered formic.If. -
however,the building or improvement is said within one year of completion,are owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.),
❑1,as owner of the property.am exclusively contracting with licensed contractors to _
construct the project(Sec.76M,Business and Professions Code:)The Contractor's Li.
cease law docs not apply two owner of property who builds or improves themon,and / \\
who Comment ua0or(s)for such projects with a canlicensed pursuant to 1M Contractor'.
Law.
`^✓
caw.
1 .ano lL
❑ ent exempt under Sec. - ,B&PCfor this reason '
Data
WORKER'S COMPENSATION DECLARATION -
I hereby aRtm under penalty of perjury one of the following declarations: \\
an and will maintain a Cenifrcate of Consent to self-insum for Worker's Compcn-
on,as provided for by Section 3700 of the Labor Code.for the performance of the
wink for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3]00 of the labor Code,for Ne performance of the work for which this permit is issued.
[.Iy WgrIme.Compensation lnamence carierand P licy number art:
Ca\Cra1J!/s ., '
CERTIFICATE OFEXEMFIFIGN FROM WORKERS'
COMPENSATION INSURANCE
oTmaectimi wed not be completed if the permit is(Drone hundred dollars(1400)
or less.)
I cerdfy,that in is performance of the work for which this permit is issued,I shall not
Law,o Calif., n ray nncunfs�be¢Wgoau eclo thenkors'Ctmpaniation -
LawsofCelifo ' Ld/4 COO !/
Applicantsem—
NOTIC L :�fter making this Cenifcate of Exemption,you should
bwom a ject to the Worker's Compensation provisions of the Labor Code,you most
ZZfonhwiAteomplywith... provisions nr Nia permit shell he deemed revoked. -. /
rN-r CONSTRUCTION LENDING AGENCY
[-r I hereby affim that Vert is a construction lending agency for to performance of
p: 7 the work fur which this permit is issued(Sec.309),Civ,C.)
W� A Lendcr's Name
a z Lender's Address
U 0 I certify that 1 have read this application and suite that the above information is
I3. H correct.I agree to comply with all city and county ordinances and state laws relating to
0 building contra(tion,and hereby aithorim representatives of Nis city to enter upon thc
>+a shove-mjudgments.
udg tlntaperty for inspection purposes
(WO agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,cosaxx aaafn ,costs and
g.fmisseswhich may in any way scene against acid City
V z A APPLICANT
of Negrsali Cof thla PRm11.
APPLICANT UyyDDF.RS NDS AND.WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCER taFl S.
Re-roofs
cofA r n Contractor Dem
HAZARDOUSMATERIALS
"hure oSURE. - Type Of ROOF
Will Ne applicant w faun building occupant srorc or handleamamrial
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health
anend Safety
Abie,Section 25532(.)+ - All roofs shall be inspected prior to any roofing material being installed,
- as �u
Will the applicant or\futrure building=open,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hnnerchi s air conuiminants as dart by the Bay Arca Air Quality Management all new materials for inspection.
rin7 P
❑Yes No,
1 have mad the h.va dousimuCan is mquirements ander Chapter 6.95 of the Califs
as Health h surety Cede,Sec'phs 25505,25533 and 25534.1 understand Net if the building
dws not current h w e m rat.that it is my.rcaponsihility m nodl'y the wcuPant of the -
mymremcnts r an a poor to'esume.0eCCap mine of0, anc� Signature of Applicant Date
o mnar¢ o„ All roof coverings to be Class "B"or better