04110028 (2) CI'CY OF CLIPERTINO - - 4a'aha x'w,�;H
BUILDING DIVISION' 'PERMilli. ' CONTRACTORAINFQRMATIgN "'
�,, -
BUILDING ADDRESS: PERMIT NO.
CHARVEZ CONSTRUCTION 04110028
OWNERS AM : PERMIT ISSUE DATE
Eo . ,. SANITARY OL N0.
RCHITECTtENGINEER 3 6 93, BUILDING PERMIT INFO
BLDG ELECT _ PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION -
<�F I hc¢by affum that 1 am located under provisions of chapter 9(commencing Job Description .. _
a with Section 700H.f Division 3.f da,Business and Profession Code.and my license is
^mayin full tome and effect.
,qz Licensee]. L'e;.t REVISION--IN HOUSE USE ONLY
ZFp Dam Comecon
Eu ARCHTTECrSDECLARATION NO NEW PERMIT" 'ISSUED/ORIG. #04030011
1 understand!my plans shall W used as Public..&
3 O t; Licensed Professional _
3 OWNER-BUILDER DECLARATION
.�<I m N
I hereby affirat I am exempt from dm Comrnman's License Law for the
o O following aahan.(Section 103I.S.Business and flofesdona Code:Any city nr county
103 which rtyuirts a Permit to coodames alcor,improve,demobh,at repair any structure
y—'^ prior to its issuance.also mquires the applicant for such permit to Ric a signed statement
tr'< ,hatheislicensedpursuantindaeprovisionsofdeComactorsLlcrLULaw(Chaper9 Sq.Ft. Floor Area ValuatigR,l 15
¢�$ (commencing with Section 7000)of Division 3 of the Business and limitations Code)or �
..
don be,as exempt daerafrorm and be basis our du alleged exemption.Any violation of -
Section tic 1.5 by any applicant for a pennit subjects the applicant to a civil penalty of APN Number - - • Occupancy Type .
not mom d m Bon hundred dollars($5001. „
❑1.u owner of Ne progeny,or my employres with wegu az daeir sole compensation. 36620024 . 00
_.
will do thnwork,end the abuctua is not Intended orolfered forsale(See.1044,Business
and Profession Cock: W k:TContactors License Law does nm apply m an owner of - Required Inspections
property who buildsorimproves daemon,and who doessuch work himselfor through his
own employee,provided Nal such improvements a2 not hammed ormRemd for sale.If,
however.the building or improvement is hath within mu year of completion,Ne owner-
builder
owevewill have the burdenof mving that he did not Wild of improve for purpose of
r,
ale.).
owner of the progeny,i m theltraivaly contracting widt licensed contractors m C`
ouuva mss not
apply
na an oro of,and rty who
Code:) pro Connector's n
came12w tlxsnotapplyman its arofprogeny who seild5or improves to da daemonC0nm& and v
who contacts for pmXcts with a connmtor(s)licnud puauam ro de Contsactoh
License Law.
01.aero under Sec. 's B&P C for this rtupn
per Dam f L8
WORKER'S COMPENSA NDECLARATION
1 hereby Non under penalty of perjury one of no mg the
I havaind will mshat ins Corifomof Consent muff-i s m fm Workers Comport- ,
nuon.n provided far by Section 3100 of Ne LOW,Code,for me performance of the, .-
work for which this permit is iss«d.
❑1 have and will maintain Workers Compensation las come.as mquimd by Sccfimn .
31M of de Labor Code,for be performance of the work for which this permit is issued.
My Worka's Compenafion Insurance carrier and Policy another am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' -'
COMPENSATION INSURANCE
(Thu section need not heeompleud if Ne permit is foram hundeaddollm($100) - -Or less.)
I certify Nal in the performance of Ne work for which this permit is banned.I sunt not
employ any person in any amber so as in become mbjen to the Workers''Compensation
Law9 of Callfomla.Date
Appis ant
NOTICE TO APPLICANT:If,after making this Cenificau of Exemption,you should
become subject to the worker's Compensation previsions of Ne Labor CMe,you most
.JZ forthwith comply with such previsions or this permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
'r~+� Ihereby&Mrm that Vert is a construction lending agency for the performance of
x Ne work fur which this permit ie issued(S«.1091,Civ.C.)
Lenders Name
a Lenders Address
U O 1 canify Nat 1 have mad ads application and sum Nn Nc above atomism.is
F' correct.I ague to comply with all city and county ordinances and sum laws rtlaung to
O V Wilding construction,and hereby audamire repasenmtives of this city to enter upon the
r W above-menumed property for inpecuon purposes.
(—' CW (We)agree to ave,indemnify and keep harmless the City of Cupertino against _
N0 liabilities judgments,costs and expenses which may in any way came against said City
V z APPLICA nefOf do gainding Of UNDERSTANDS A'ND rWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC _ULA 0 .�0 -
/i Re-roofs
sere of Appli mVGantacwr Da¢
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future Wilding«cupmumrc or handle ardour aural
az dcfinc0 by the Cupertino Municjpal Code.Chapter 9.12,and Nc He d Safmy
Code,section 3553200' �N/ All roofs shall be inspected prior to an roofing material beim installed.
E]res P P Y g g
wn the applicant or comm Wilding«capant aha equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it haardna air conammants az recd by Nc Bay Ams Air Quality Management all new materials for inspection.
seta?
Q Yes u
I have mal dae hvardnus materials mquimmcnts under Chapter 695 of dace Califor
-
niaHcalth&Safety Code.Sections 25505,25533 and 25534.1 undconerm Nm if dr Wilding
does not c amid h�c ana Nat it u my repnnodulhy to motif y the occupant of dace
mquim nrwhich s nmelPdorwimumecofaCerdfiemofa.cvpmcy. Signature of Applicant Date
ow 9r authorised agcm — Dain` All roof coverings to be Class"B"or better