04030011 (2) F
TY OF CUPERTINOBUILDINGDIVISION PERMIT CONTRACTOR4NFORMAR9,NDING ADDRESS: PERMIT NOO 4030011
290 BONNY nR
Its NAME: PERMIT ISSUE DATE
TERRY THAM
SNL:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
you LICENSED CONTRACTOR'S DECLARATION
zu Ihereby.formiv 1amlicensedunder
nd!PromnaofChapter 9(commencing Job Description
4Zm with Section ndefecDividomJof the Business coed Profwion Code,and myli<crt¢is
n<a in full forte and effect.
ti
''y,i Licros.aass e• ADD 1024 SQ. FT. /REMODEL
n F l Dam Contractor
ARCHnECTS DECLARATION j c
1 understand my plans shall be TS u public TION
'0U
;OG Liccnaml Professional
S OWNER-BUILDER DECLARATION
n.1
I hereby ME.that I am.acmpt from the Contractors License Law for the U
o O following reason.(Section 7031.5,Business and Professions Cade:Any city or county
K m which requirts a permit us stomMeL alter,impmve,demolish.or repair any suucom00
prior m its issuance.atm rcqulrs the applicant for such Permit o fisc a signed statement
that M is liccooml pursuant to the provigiOnS Of do Contractor's Limnsc Law(Chapter 9 Sq. FC Floor Area Valuation
wi--C (commencing with Section 7000)of Division 7 of the Business and Professions Couc)or
'd that W is amrapt IWrefrom and the basis for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant in a civil penalty of 3 GkPXQ b`A*er0 0 Occupancy Type
not mom than five hundred dollars($300).
❑I.a owner of the property,or my employees with wages as Noir sole compensation,
will do the work,and the swmum is not intended or offered tressle(Sa.7044.Boum;
and Professions Code:The Contractor's License taw does not apply On an owner of Required Inspections
property who builds or improve thereon,and who doeeouch work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion.the notes.
builder will have the burden of proving Net he did not Wild of improve for purpose of
sag.
I,construct
owner of the property,,B exclusively contractingfess with )TheeComot ht's m
come,La the es not (Sec.o an Business and Profusions CodeI The es demo.Ld I I
who emoracts
law dao not apply w m owner of property who Within of improves Neuron,and QV
whense Locts far such projects with acanvmmrts7licerrsed pursuantm Ute Convactofa L a
License Low. // /�• /k„���J//C
❑lamzcm
eplunderSee .Bg:PCfor Nres
is ort
r Date /0 0� C,
WORKER'S COMPENSATION DECURAT
1 hereby alum under penalty of perjury,one to the following declaration:
73011.1
s aro will maintain eCion37W of Consentater ode for for Workers Compcm
a provided for by Section 3700 of she Inbor Code,for the performance of Nc
r which this permit is issued.
ve and will maintain Workers Compensation Insurance,a required by Section
the labor Code,for Ne performance of the work for which this permit is issued.
rkcra Compensation Insurance canner and Polity number are. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I
(Thu section used not he completed if Ibe Roth is fur onehundfed dollars(1100)
or less)
I certify that in the performance of IW work for which this permit is issued.I shall not .,
employ any person in any manner so as in become subject to the Workers Compensation
Laws of California.Dam
Applicant !
NOTICE TO APPLICANT.If,aper making thin Cenifm3uc of Exemption,you should IIIIL_--
W.ome suhjccl to the Worker's Compensation previsions of the labor Code,you most
.J,Z, foMwiN comply with such previsions or this Perm it shall be deemed mvnked.
z OCONSTRUCTION LENDING AGENCY
[-+� I hereby affirm that Nem is a contraction lending agmey for the Performance of
D: > the work for which this permit is issued(Sec.3097,Civ.C.)
lander:Name
=Z Lenders Address
fJ Q 1 certify that 1 have read this application and state that the aW ere infornmun is
t" correct 1 agree to comply with all city and county ordinances and sum laws misting to
0U building convection,and hereby autoosemlrruenuadwas of this city to enter upon the
}� aW.-mentioxd P.Kny for inspection purlmxs.
(We)agree to ave.indemnify and keep harmless Um City of Cupenirm against 42 111
liabilities,judgments.coats and expenses which may in any way accem agmnl said City /
U Z Aconsequence or to granting of tPermit.
LICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date r
SOURCE RE ULATI NS. ,
u r'� Re-roofs
nawm of ppRcaMcmmoamor Dare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will"'MI
c applertino M
icant ter fumm building uceupmuto.of handle barudous material
defined by the Cupunicipal Code.Chapter 9.13,reit the Health and Safety
e Section 255374)7 �! All roofs shall be inspected prior to any roofing material being installed.
V1❑Yu .
V311 the applicant or home building Occupant use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
7d.
t barafdmo air contaminants a defined by Ibe Bay Arta Air Quality Management all new materials for inspection.
rict,
n Yes on
I have real Nc hvardmus materialsmyuimmcnts unJcr Chapter 6.95 mf Nc C.1do.
Hcalth&Safety Cock,Scn..85(15,15533 and 75534.1 understand t uif Nc Wilding
not curcnUy have a tenant Nat it is my ruponsihility to nastily the oceupanr of Nc
uimmcnk hichmusIbeme,priortoissuanceofaCerdfcateofOcaPan.. Signature of Applicant Date
O v b/
o furauthon.dagem Date All roof coverings to be Class "B" or better