03040114 CITY OF CUPER'I'INO "`�'�' '•>* :'
BUILDING DIVISION PERMIT i CONTRACTOR TNFORMATTON d
Yff'61"INNOLFE RD NORTHWEST SIGNS PERMIT NO.03040114
5��1' S'`IEROEBUCK AND CO325 WASHINGTON ST. PERMrrLSSIM70 2/2003
(831) 469-8208 SANITARY NO, CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BL 1 PLUMB MECH
0 0
±00 LICENSED CONTRACTOR'S DECLARATION
�mF I hereby.ffirm that 1 am licemod under provisions or Chapter 9(Commencing IOb s Iptl
Z" with tionhggB of Divipion Jof the BusineuyO Prohuiuns Code.mdm lice�acu 11
acy iicen e(t�+�onde �L J 1 $GJ CI -�
q: LkcnwSlus Lk,r, y SIGN 1111JII1
D Cun CWP
ARCHITECTS D RA
I W< 1 understand ery plans shall he used n public or a
>y
'Ot, Liccnxd Portfolio nnel
y ,S OWNER BUILDER DECLARATION
2<E 1 hemhy affirm'hot I onto exempt from dte Contractor',Co License Law for the
O O following toren.. ennitul 8131.3,Business and improve,
d cions Cod,:Any city or county
3$ which requires a pennh re cnvtrueL alter,improve,h Permit
erm t t nr e a sig any structure
tpoor hat hnslts cennCo,alnnquins the
ovisiosofcant for such P,nnitmicese Lawdwhaptert
� <
that licensed pursuant 70the of Division
of NC Contractor's Professions
(Chaptcr9 Sq. Ft. Floor Area
2 s (cat he
(commencing it inciuen and trDiaiisfrn(NCBusinexeandon,Any
Codc)ter
3 Net ion is exempt Ncmfrom and the buil far be cts exemption,t,Any violation of
Section TO31.5nany applicant for&permit&ubjecu BeNe applicant toacivil Penalty of 3±DTd aie®k.er p p Occupancy Type
not more Nan Rw hundred dolhn(5500). 10�d V' V"
01,as owner of the property,or my employees with wages as Noir pole compensation, �f.g�y''�T�ii�
will dothe work ands:TheCmbaotimmnd)dmoRe does
apply in 44,an
ed,or 304 - ROUGH �( RWAlens
and Professions Code:The CO.is Out i Llama Law doss not apply to an owner of
pnpeny who builds or improves thereon,and who doessueb work himaelfor through his 505 - FINAL E ECTR CAL
own employees.provided that such Imprmo menu arc not intended oroffaed(orsele.If.
however.the building or improvement Is told within Om year of Completion.Ne owner.
builder will ban de burden of proving that he did not build or impmw for purpose of
sale.).
❑1.as Owner of the propeny,am eaclusinly contracting with licensed convectors to
construct the project(Sec.7044,Business and Profession,Code:)The Contractors LF
ave law does not apply to an mono of properly who builds or impmw thereon,and
who concocts for such projecu with a contractor(s)licensed pursuant o On Convactoes
License law,
❑1 am exempt under Sec. .B&P C for this won
Owner Data
WORK ER'S COMPENSATION DECLARATION
1 bercby affirm under penalty of perjury oro or the following declan ions:
haw and will maintain a Cenificam of Covera to self-irrure for Workers Compete
n7ion,as provided for by Seetion 3700 of the labor Code,for the performance of Ne
.,it for which this permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as required by Section
3700 of Me labor Code,for Ne performanec of the work for which this Penni,is issued.
My Wo/rker's Compen anon I moans,carrier nd li rumhee,am:
Cat(iyr:TPoI' oO: 1 O KE
ll-- RTIFIC OMPE SATIONINSUON RAN ORKERS'
COMPENSATION INSURANCE
Mosseetion need not In completed limit Permit is for one hundred dollars(5100)
less)
1 minify Not in the porrnrmanco Or Ne work for which this permit is issued,I shall not
employ any person in any manner so as to become subject In The Workers'Comp,mation
Laws of California.Det.
Applicant
NOTICE TO APPLICANT:If,after making this Coni rteatc of Exemption,you should
become&object to the Worker's Compensation previsions of the Labor Code, no must
7Q forthwith comply with such provisions or this Permit ha deemed revoked.
Z5; CONSTRUCTION LENDING AGENCY
I hereby affirm Nat Nero is comWction lending agcwy for Ne Perfurmonce of
5; dm work for which this permit is issued(Sec.3091,Civ.C.)
0 Landeh In c
z Lender's Addm.
;)Q I censtr that,have read this applhorim representatives
and auto Net Ne ebow information e
y f~ contract.I agree 7o comply with all city and county ordinances and suite laws misting to
�O abovengcnnawctiro and hembyeetiorinnprexnutiws u(Nis city mcmer upon Nr.
ehovc(We)agree
topcny for inspection keep es
(We)agree a.saw,indemnify and kap M1ay in an the City n Cupertino s against
Z Iiacosequence f Megrauing of this circuses which may in any way accrue gain.said City
L) Z A APPLICANT
NDERSTA of this Permit.
^' APPLICANT UNDERSTA OS AND WILL COMPLY WITH AI,L NONPOINT Issued by: Date
SOURCE REG L TION `T///I
Re-roofs
gra re Ito HAZARDOUS MATERIALS DISCLOSURE Contractor Data Type of Roof
Will Ne applicant or future building occupant store or handle henrdous material
as defined by the Cigxmmn Municipal Code.Chapter 9.12,and the Health and Safety
Calc.Section 25532(¢)+ All roofs shall be inspected prior to any roofing material being installed.
ao❑Yrs QL'u
Will the applicant or uwrc buildipg occupant us„yuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,ones air mntaminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
Diwrictl
❑Yes rod 1 have roaJ the hanN,ma materials requirements under Chapter 6.95 Of the Califon.
.is Health&Safety Code,Sections 25505,25533 and 25534.1 trokntrnd Nm if Ne building
does not cutremly hove a tinam,Net it is my responsibility m notify the Occupant at Mae
reulmmenu which mast mel bra.Metairie.nr.cenl"S Oceapan,y_ Signature of Applicant Date
� � All roof coverings to be Class"B" or better
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