03110009 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT C0NTRACT0R,INFORMATIO,N
BuaDINGADDRESS: R. K. BERRETT CONSTRUCTION PERMITNo.03110009
O\'JNER'S NAME: 6151 CALLE DEL CONEJO PERMITI55UEDATE
.JE: (408) 268-0530 SANITARY NO. CONTROL N0.
AR CHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MICH
O o LICENSED CONTRACTOR'S DECLARATION Job Description
C7 O O
i se 1 at affirm that I am licensed under provisions of Chapter 9(commencing p
i .it
Section rflflB)of Division Sof Ne Busineaand Professions Code,and my license is
in full force and effect. P�
L;cemsc etas Lle.4 REMODEL (BATH/BEDM/CE `VW>�WS)
e^ Da¢ Commerce °°tee c�•
• ARCHITECTS DECLARATION OCT
i w< I understand my plana shag he used a p.hlie reenrds
o Loomed!Professional 9 2004
OWNER-BUILDER DECLARATION
a I I north,affirm that I sm exempt from the Cisommor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which mquims a permit m construct,alter,improve.demali<h,of repair Soy structure
prior m its issuance,also requires the applicant for such permit m file a signed statement
?s j that he is licensed pursuant to the provisions of the Commctois Licenu Law(Chapter 9 Sq. Ft. Floor Area atlon
4H (commencing with Section 70K)of Division 3 of the Business and Professions Code)or
.. thm he is exempt shoMfmm and the basis for the alleged exemption.Any violation of 35606032 . 00
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more man fin hundred dolls(s500). P Y YP
❑I,a owner of the property,or my employees wish wages a their sole compensation.
will do Ne work,and the swetute is not intended or offered for sale(Sm.]044,Business
and Professions Code:The Conmctors License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himselforthrough his
own employers,provided that such improwando;are not intended or offered forssle.If.
however.me building or improvement is sold within mom year of completion,the owner.
builder will have the burden of proving that W did not Wild or improve fm purpme of
salt.).
s V as Owner of the property,am exclusively contracting with licensed convectors to
coammt the project(Sec.]044.Business and Professions Code:)The Contractor's Li
cave Law does not apply to an owner of property who Wilds or improuss Nemon,and
who contracts for such pricit with a co ver csor(s)licensed pursuant to the Contractor's
License Lew.
❑ I am exempt under See ,B&PC for this moon
W Date lI B
VpRKERSOPMPENSATIONDECLARATION
I he by affirm under penalty of perjury ore of the following declarations: .
I haw and will maintain a Certificate of Conant to self-insure for Worker's Comfort.
sation,a provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued.
El 1 haus and will maintain Wurksr's Compensation Insurance,as required by Section
37M of the labor Code,for the performance of the work for which mu permit is issued.
My Workers Compensation Insurance eerier and Policy number arc:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseetiml need not hecompleted if tk permit is for ons,hundred dNlara(51(1(1)
less.)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner so as In Wcume subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this CeniOcate of Exemption,you sWdld
become subject to she Workers Compensation provisions of the Labor Csoe.you most
D forthwl In comply with such provisions or this Permit shall W second mvnked.
OCONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency fur sW performance of
3' 7 the work fur which this permit is issued(Sec.3097.Civ.C)
ij 0 Lender's Name
z Lenders Address
;J Q 1 cett;fy Nat 1 have read this application and sum that she shove information is
correct 1 agree to comply with all city and county ordinances and state laws relating to
Dbuilding condonation.and hereby eushorim ep¢.ensativcs of this city to enter upon the
U shove-mc judgments,
udg d prop outrty for ie pecoonenes purposes.
CL (We)agree In save,indemnify and keep harmleas Be City of Cuprnino against
h liaemsexPerre of
limmindof this Kim it.M1mryin any way accrue against said City
;Jz in consrquenec of the granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGO TIONS. ,S54 fI/ C
Sig plica ontrnemr
Re-roofs
ZARDOUS ATERIALS DISCLOSURE Q.a Type of Roof
dte applicant tar future Wilding occupant stem or handleNteri
auus maal
u m.definedSer by do pe
Cuttino Municipal Cody,aspectaspectHe
r 9.13,and the Health and Safety
Calc,Section 355320)?
❑res p1Nu All roofs shall be inspected prior to any roofing material being installed.
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
it hazardous air contaminants as defined by the Day Arca Air Quality Management
isloct? all new materials for inspection.
0Yes IrNu
1 haus read the hazardous materials mquinements under Chapmr6.95 of the Califon
ria Health&Safety Cons,Sorrento 25505,25533 and 25534.1 understand daifNr Wilding
dors not currently ban a truant Not it is my res ronsihility on notify tM meopsm of the
mquiromen h`=na rtpd iauanccofaccmrcawofOccupaney. Signature of Applicant Date
owntyulnprlLAYrent �/ All roof coverings to be Class 'B"or better