04060133 CITY OF CUPERTINO
BUILDING DIVISION PERMIT , +CONTRACTUR$xNF'U2M-A' ON:
BUILDING ADDRESS: PERMIT NO.
ATLANTA CONSTRUCTION INC 04060133
OWNER'S NAME: PERMIT ISSUE DATE
MAIE: SANITARY OL NO.
ARC HITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
+�o'z LICENSED CONTRACTOR'S DECLARATION Job De 1 O
r'2 I heroby affum Net 1 am licensed under provisions of Chapter 9(commencing
with5 )of Divii of NCB.mm,aeaytrPlate Ism Codc,a dm li I.
e
^ w In fullf red cBea ✓
�� Lke= nnaLi[.p u� � HOUSE DEMO SEP 1a� 2004
Dem Contras 16" I ,ave
ARCHITECTS OEC 6�� �(/�
-r I undcntanJ my plans shell M used u public months
BUILDING
Licensed Professional
OWNER-BUILDER DECLARATION
<E 1 hereby affirm Nal 1 em exempt from the Contractor's License Law for the
O O following mason.(Section 7031.5,Business and Profossiuns Code:Any city m county
k 3 which requires a permit to construct.alter,improve,demolish,or repair any structure
priurto missuance,almmquitas Ncapplicant forsuch permiuo 0leasigned statement
ss< that he is licensed pursuant to the provisions of the ContrumriLicense aw(Chapter9 Sq.Ft.Floor Area Valuation
sa � (commencing with Section 7000)ofDivision3of NC Business and ProfessionsCmle)m
y
that be u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of APN Number Occas ane e
not mare than five hundred dollen($500). - P Y TYP
❑I,uownmofthepropcny,mmyemployceswithwagumtheirmlemmM=tion,
will do the worlt and theatructam isnotimendedoroffered foreslc(See.7ndd,Buineu 22042 . 00 Required Inspections
and Professions Code:The Convacmrs License Law does not apply to an owner of q p
progeny w ho bui Ida car improves thereon,end who dors such work himself car through his
own employee;provided that such improvemens an unintended oroRered for sale.If,
however,the building or improvement issold within one year of completion,the owner-
builder will have the burden of proving that M did not Wild or improve for purpose of
tdn3.
❑1,as owner of the property,am exclusively convecting with licensed contractors;to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Lt.
came law dors not apply to an owner of pmpeny who Wilds or improves demon,and
who contracts for such projects witha conuactor(s)licensed pursuant to the Conuactoet
�tcense Law.
I am exempt under Sec. ,B Al P C for this mason
f Owner Date-
WORKERS
am
WORKERS COMPENSATION DECLARATION
I homey affirm under penalty of perjury one of the fallowing declarations:
have and will maintain a Condiment of Consent m self-insure for Worker'aCompen-
mtiun.as provided for by Section 3700 of dm labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurence,as required by Section
3700 of Ne Labor Codc.for Ne performance of Ne work for which this permit is issmd.
My Worker's Compensation Insurance carrier and Policy number am:
Cu _ Policy
IJ CERTIFICATE OF EXEMPTION MWORKERS'
— COMPENSATIONINS NCE
(This section need not Mcomplcmdi0 t is for one hundred dollars(SIM)
or cera.)
1 certify thdl in the performance of the work for h Nis permit is is ,l atoll not
employ any perynin anymanncrsn bre m ubjemt tl gSrkc 'edmpcnsadon
Laws of Calif am49
Applicant
NO CF TO A CAVf. `ma i. cRlncato o(Exe lion,you should
be�o uhjcct to Ne WoherS CamPcasation provuiona of Ne Lahn Cadc,you man
.JO to th comply with such provisions or this permit shall W doomed revoked,
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a construction lending agency for the Performance of
!Yi ti
the work for which this permit u issued(Sec.3097,Co.C.)
6Wi Q Lender's Name
] Z Lender's Address
U Q I certify that 1 have read this application and sum that Ne above information is
Dr H building l agree to comply with all city and county ordinance and ass laws relating e
QV buildingconswctionand hemhyarcpresenudvu of this city Menter upon the
W ahovcmc e)wood
ogre property for inspectionnifaprep=a
We)agree to ave,indemnify and keep buret=the City of Cupertino against
faq liabilitiu,judgments,coats and expenses which may in anyway accrue against said City
U Z in consequence of the Sonning of this Permit.
t..t
APPLICAta UNDERSTANDS AND WILL COMPLY W H AL NON-POINT Issued by: Date
soURCER ULATIONS.
_� _ in,4 rd L D � - A Re-roofs
I mreef ppli � vacm
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum builtling occupant store or hantllc harsrtlous mamnal
as defined by the Cupertino Municipal Code.Chaplet 9.12.and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes V.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
n huardous air contaminants u Jcfined by me Bay Arca Ail Quality Management all new materials for inspection.
lurid?
❑Yes �;(Nu
1 have road die huardnusmaneriala royvimmcns unJerChapmr 6.95 of the Califor-
niaHcaW&Safety CWtl,Sdbuons25M5,25533aha25534.1undcrsmuddler, abuilJing
does nos cuEd�gcml
a mnanr,that itis my reapmuibility m notify Ne occupant oI
aqui cmalMmetpnoryin ccor.cenif, ofOcup Q Signature of Applicant Date
Z1
b All roof coverings to be Class "B"or better -
Ownerorown Doc