04020048 CITY OFCUPERTINO .sfNIFQP�MATJO'BUILDING DIVISION PERMIT ,aC� RF� �QR� "
PERMIT NO 04020048
BUILDING ADDRESS:
PERMITL'SUEDATE
r R'S NAME:
s AISESTATIRZT) SANITARY 0. ONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECiffINGINEER:
BLDG ELECT PLUMB MECH
aIOO LICENSED CONTRACTOR'S DECLARATION Job Description
Z I hereby affirm Net 1 am Ikensed under previsions of Chapter 9(commencing
< with Scotian 7Q7n)af Division Sof NC Busioessarld Professions Code,and my license is
a<� in full to=and effect. TEMP. PERMIT-EXPIRES ON 03/07/04
j ZLicense Class Ll,.0
z Dam
Contractor. ORIG. #03100046
t� ARCHIIN-1 S DECLARATION
a i understand my plans shall be uSeJ as public records
as
.'�0.G Licensed Professional
OWNER-BUILDER DECLARATION
if I hereby affirm but I am exempt from be Contractor's License Law for the
i O O following mason.(Section 7031.5,Business and ProRmiulu Code:Any city or county
k$ which requires a Permit In construct,alter,improve,demolish.or repair any structure
to"w' prim to its issuance.also nurtures the applicant for Such permit to file a signed sentiment
that he is licensed pursuant to the provislo"or the convector's License Law(Chapter 9 Sq.Ft. Floor Area Valuation$52
Id $ (commencing with Section 7000)of Division of the Business and Professions Cow)m ..
.. that he is exempt therefrom and Ne basis for the alleged exemption.Any Welsh on of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pen•Ity of APN Number Occupancy Type
not mom than 0w hundred della.(55001. '
❑1,m owner of die property.or my employe"wide wages ea their sole compensation, 31620037 . 00
will do the work,and the swctum is not immmaed or offered for We(Sec.7M.Business Required Inspections
and Pmf"sions Cock:The Contractor's License Law danot apply to an owner of tl p
property who buildsorimpreves Jmrcon,and whodoesmchwarkhimealfor through his g.
own employees,provided that such improvement se @
e not intended arored forsue.If. O ry Permit
however,be building or improvement is mid within one year constriction,be owner
builder will have thee burden Of proving Nat he did not build w improve for purpose of
,yrs.). Issued prior to plan check completion
,as Owner of the property,we exclusively contracting with licensed contractors to Contractor and/or owner accept complete
wet the project(Sec.7W.Business and Professions Cade:)The Contractor's Ll-
ore
carve law docSwnot•pplytoanOwnerofproperty who builds or improv"thereon.red, responsibility for correcting additions,
who contracts for such projects with a concmForward r(s)licensed Foard to the Contractor's
Li en"L. C/J� omissions and revisions on
❑lam c: 4 a" c. B&�aP,Cfm N' rcuon
r �•O-zg� amW t-i completed Blue Prints. -
WORKERS COMPENS �ION
I hereby affirm under Penalty of parjury one of thefollowing declaration: Permit good thi days
I have and will maintain aCe"Ificam of Consent to Sel6inaum for Worker's Compen. {�
satNn,as previded for by Section 37M of the labor Code,for be Performance of be From
work for which N.Permit is Issued /
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for be performance of the work for which this permit is issued. SI nature
My Worker's Comp risedon Imusawe carrier and Policy numbe,mw s� g _
Carrier: Policy Na.;
CERTIFICATE OF EXEMPTION FROM WORKERS' IJate• .
COMPENSATION INSURANCE
flhis Section need not be completed if the Permit IS for one hundred dollars($IM) rr`/�P� /•q�,(� !/ VT��(.(/J
of 1055.1
1 Certify that in be Performance of be work for which this Permit is issued,I Nell not ,�.{II 44
employ any winner in m m in any manner to become subject to the Workent Com �
pemll fC
I-Swa of California.Dam -'7/ 1
Applicant
NOTICE TO APPLICANT:If,after making this Corollate of Exemption.you should
become subject to the Workers Compensation previsions of be labor Code,you must
aJ O foMwith comply with such provisions or Nm
is Permit shall be decreed maked. _
z55 CONSTRUCTION LENDING AGENCY
Fti Ihereby Sir.that One.issconsmuctun Coding agency in,be perfurmama of
•7 the work for which this permit is issued(Sec.3097,Civ.C.)
fit Q Undoes Name
z Lender's Address
U 1 certifyNat 1 have read this application and sum that the above information is
iy H COOMCL 1 agrea to comply with all city and county ordinances and asst laws misting to
O U building convection.and hereby authorise repmsanmives of Nis city to enter upon the
W
above-mentioned property for inspection nspurposes
G (We)time to save,indemnify and keep brooding the City of Cupeniro against
pj liebllitim,judgments,cost andexpenses
which may in any way accrue against said City
U Z in consequence of the granting of this permit.
— Dat
APPLICA L NON
-JOINT NO AN ILL COMPLY WITH ALNO - OINT Issued by:
SOURCE AnGN
I Re-roofs
S gnauw of App mxmVConuamlm' D m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applimntorfummbuildingoccupantai morhandlc havmdous manurial
m defined by the Cupertino Munici al Coda,Chapter 9.12,end the Health and Safety
de, 0Co..zss3z(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea Nu
Will the applicant or(severe building occupant tau equipment or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
7d.s
t ha'raNnue air cbnymin na t a5llc0ncd by Ne Bry Ar"Air Quality Manegemcm all new materials for inspection.
❑YrsI have mad Ne hvammusmaterialson uimmcnm underchapter 6.95 of the CalifonN"ide6 Safety Code Sections 25505,25533 md25534.1 understand thetitue Milling
rat nilly haw ren 4 Na itumytesporo bilitymnoulythow, .1of Nc
vire hichmust daporpissunccortCcnificatecdoccu ar. Signature of Applicant Date
1 b (l All roof coverings to be Class "B" or better
ncr or authori'r d agent Dam