04030042 F ERTINO "0 �—777-7777,,,,
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BUILDING DIVISION PERMIT
3UILDiNG ADDRESS: J. T CONSTRUCTION PERMIT"°04030042
01 � 11 11
ERNAME: PERIMITISTUEDATE
ALAN WONC- tT)VANTT) 1720 OCALA AITF n c;/2 o n 4
ONE: SANITARY NO. CONTROL NO.
(408) 272-4570
mi
ARCHDIRC1711INGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC711
08 Z, LICENSED CONE'RACTOWS DECLARATION
I hereby enno that I am licensed under previsions of Chapter 9(commencing Job,.Description
with Section 7001b.f DIA.W.3.f the Buniman And Popessmat CrAia.imultry license is
in full to.and.1fivet.
TEMP. PERMIT—EXPIRE ON 04/05/04
License Class—Lic.Is
Date—cmarmuer ORIG. #03100046
4
411 ARCHITECTS DECLARATION
I undersand my plans shall be need As public records
Licensed professional
OWNER-BUILDER DECLARATION
I hereby anion that I am exempt from the Contractur's License Law for the
follnuing mason.(Section 7031.5,Business and Professions Code:My city or County
which requires a Permit to Construct,alter.improve,dconothh,or repair any shrocturc
prior to its issuance,aim requires the applicant forsuch permit to rile a signed statement Sq.Ft.Floor Area Valuation$52
that he is licensed pursuant in the prevision or Me Continuator's Liccom Law CO
haptc
(commencing with Section 700E.1'Division 3.f Me B..Incsumd PmrAA,i...Code)Or
Met he apt Marrefrom and Me basis for the alleged exemption.Any violationof
Section 7031.5 by a"Applicant for a per elt subjects the Applicant to A civil Penalty of APN Number Occupancy'l�pe
an.
net M.live hundred dollars($50E.
0 1.an Owner of the property,or my employeeswith wages a their note compensation, 31620037 . 00
will do the AuAlla.And Me structure Is not intended r.rrmad for sale(Sm.7W,Business
And Proessi.m;Code:Th.Contractors License Law does out Apply to an owner of Required Inspections
property who bee ildAor improves Maroon,and whdon.tech wakininnsalf orthrough his
own employees,provided Met such imp000meonts are not Intended orofferad for sale.If.
however,the building or Improvement is sold within one year of completion,Me owner,
budder will have Me burden of proving that he did not build or Improve for purpose of
LA.
1,an Owner of the poupmr,,am cachudycly contracting with licensed contractors to
net dm project(Sec.7W,Business And Prodfiessimm Code:)The Contractors Lt.
sen Law does not apply to an owner of property who builds orimprom demon.And
who contracts,forsuch pmjeca with a contractorad licenwel pursuan co cute.
License Law.
0 1 Am der B1 r, A
Da
I hereby affirm under Penalty of perjury one of the following decarations
. wokKERS COMPENSATION DEC TIO
I he-
;And will maintain A Continues at Consent to"If-insum for Woricer's Co:mpcn.
nation,As provided for by Section 37M of doe Letter Code,for Me performance of Me
wets for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of In Ube,COCA,for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier.—Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(EM;atection recd not be completed If the permit is fatomhundend notion OH00)
or ks&)
I Certify that in the performance of the work for which this permit is issued,I shall not
employ any penton in any marmarm an to become subject to the Workmy CDAnPCA&Athn
Law.or California.Care
Applicant
NOTICE TO APPLICANT-.If,After nn.kfiq;this Cardinale of Exemption,you should
become subject to Me Workers Compensation previsions of On,Labor Code,you most
Z forthwith comply with such provisions or this permit shall the second mvoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that More is a construction lending Agency for the performance of
Me work for which this permit is issued(See.307,Civ.C.)
Landers Name
P,
.7 z Lender's Address
U 0 1 certify Met I have mad this Application and same that the above information is
correct,I Mme to comply with all city and county ordinances and same laws reading to
0 U building Construction,And hereby authorne roPmemnaliven Of this City 10 Amer often tho
W alaovc-mentioncd property for inspection purposes
Cl. (We)Agree to save.indemnify and keep harmless the City of Cupertino against
,A liabilities,judgmends.Cosa And exit
which may In any way seem against said City
Z in conamucocc of the granfing,of Mi'PowbiL COMP POINT
APPLI U STA CS AND WILL Issued by: Date
SOU So NS 70 ,
alum ofMplicart/Convacto Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the,applicant or future building occupant atom or handle bacandous matum.1
AA6Oc1112.`o T1,C1117)"im,Municipal Cade.Chapter 9.12.and the Health and Safety
,1.E K All roofs shall be inspected prior to any roofing material being installed.
]Y. No
Will the pplicarl Or future building mcupord usc equipment or Cee a.which If a roof is installed without first obtaining an inspection,I agree to remove
it hatardous air comerninams As defined by Me Bay Ana Air Quality Management all new materials for inspection.
7Diauict?
MYCS All.
I how mad Me harammus maturials requimmenot under Chapter 6.95 of MA Califto,
MaHmill, Cly I u I r 25505 25533 d 25534.1u*.Mr thairthe building
a' An
Jas not curt 11 ve air Met O.Y.Ap. lolnoel' Me occupant of the
responsibility
m to AE ante
u
qtimmc nn�!Nl A pro issuarcl.f.cA. amen. Signature of Applicant Date
All roof coverings to be Class"B"or better
Mror to authorized agent Dau I