03090228 (2) i
Y OFCUPERI'INOu .3sBUILDING DIVISION PRRMIT CONTRACTOR INFORMINGADDRESS: LANDSYSTEMS LANDSCAPE PERMITN003090228
14n rAmyom nAK WAY
R'S NAME: 3113 MIDDLEFIELD RD PERMIT ISSUE DATE
CARR DE VRIOSTE 11 /12 /2003E' (650) 851-2793 SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
300 CONTRA=R'S DECLARATION
U 1 ion70 arfirm that I am f the
under and
Pr previsions of Chapter 9 my ficcncing Job Description
with Section 70(Its)of Dlviaion3o(Ne Busiwsend Profcainns Code.and mylicenseb
&D,a in mu Come cnderrecte y,Wy7 ` 9 Y3 ARBOR/RETAIN WALL/LANDSCAPE `q
j.�Z License Cly, Lic.N FINAL`D
Nv Ou Cont
g ARCHITECTSQARATION
WU I understand my plans shall W used u public records -
yQ5 LicensedPmfcaimmi DEC 1 .9 2003
OWNER-BUILDER DECLARATION
gf I hereby alarm that 1 am exempt form the Contractor's License Law for the BUIL
o O fallowing mason.(Sued..7031.5,Busineu and Pro(essinu Code:Any city fir county
5 m� which requires a Permit to construct,elms.improve,demolish,or repair any structure
_iy prior to its issuw ance,tlrcqurhe applicant for such permit to Gla•signed stoumenl
pZ< that Wulicensed puuuamtoLithe pmviSOMOfdeCOmboxhrlUmnselaw(Chapter 9 Sq. Ft. Floor Area Valuation
u+i-O (commencing with Section 7")o(Division 3 ofthc Business and Professions Code)or
;? $
Et'lo,or exempt therefrom and the bust for the alleged eamptlon.Any violation of 34260001 . 00
Section 7031.5 by sty applicant for a permit subjects the Applicant o a civil penally of APN Number Occupancy Type
not more than five hundred dollars(5500). P Y YP
❑L a awnerk,and
pmpetty,structure employcu with wag.u itle(sole eom,Business
will Pr the work,ands: oContractor's
ontisnotinLnded orow it not a(Sec.to ad,Business
and Profwh ore Code:Thc Conpm on.Liaise Law doh not apply to an owner of Required Inspections
now em who buildsorimproves Neuron,and who dauuchwork himselfedthrough his
awn employee,provided that such Improvements ace not Intended mo0hed forthe Asia.own r..
however,the building orimprorcmcnnissold did not
year or Improve far theowner.of
builder will.arc Ne burden of proving Nn W did not Wild or improve fur purpose ar
isle.).
D h as owner of the Impar,am exclusively contracting with licensed Cannnclan to
construct the pmjecl(Sec.7014,Business and Professions Cade:)The Contractor's Li. _
cense law dors not apply to an owner of pmPar,who Wilds or improves Neeson.and,
who contracts for such pmjecu with a conaacmr0)licensed pursuant o the Cantralara
License law.
❑I am exempt under See. ,B B P C fm this recon
Date
WORKER'S COMPENSATION DECLARATION
1 hereby of lon under penalty of perjury one of Ne following declaration,:
I have and will maintain a Ccnifieom of Consent o self-insum for Worker,Compen.
Wian,as provided for by Section 37W of the labor Code,for ow pedormma of the
work for which Nis permit is issued.
r-11 have and will maintain Worker's Compensation Insurance,as mquimd by Section
37M of dtc Labor Code,for the performance or the work for which trim Permit 1,Issued,
My Workers Compensation Inswecarrier and Policy number art:
Policy o.:G✓C ^J2j-,6?- d'rrr
CERTIFICATE OF EXEMMON ERW WORKERS'
COMPENSATION INSURANCE
(This seciinn need not becomplemd if the remit I,forone hundred dollars nb0B)
or las.)
I comfy that in the Performance of the work for which ibis Permit is issued,I shall not
employ any person in any manner an As in become subject to the Workers Cnmpoyation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:It.spur making this Certificate of Exemption,you should
hecome subject to the Worker'.Compensation previsions or the labor Code,you must
JO foMwi th comply with such provisions or this permit mall be deemed revoked. -
r N CONSTRUCTION LENDING AGENCY
r " (hereby&from that Vert in convection lending agency for the performance of
^1. the work for which this Permit is issued(Sec.3097.Civ.C.)
GQ Lender,Name
z Lenders Add.
J Q I comfy that I hale read this application and sum that the above information i,
L4 F carom 1 agree to comply with all city and county ordinances and stoic laws misting to
V building convection.and hereby Authorize representatives of Ms city to enter upon the
W shave-mentioned to an for inspection an keep cs.
gy (We)agme to cove,indemnity and keep harmless the City of Cupertino against
rn judgment.the costs and expcuesmit. may in my way mcmcapinst aid City
V z A consequence of the gmnllag Of this Permit.
"-� APPLIC UNOERSTANy6AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EOU�,A71pN5//L_
G' w/L lx
? Re-roofs
Bi tum of ApplicmUConRDO
HAZARDOUS MATERIALS DISCLOSURE as Type of Roof
WiII dm applicant or future Wilding acupant smrc or handle husAaa makrial
defined by the Cupertino Municipal Cock,Chapter 9.12.and the Health and Safety
A.S-I ea 25532 A)?
DYea 0 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or futon building occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
it harasdou air contaminants a defined by the Bay AMA Air Quality Management all new materials for inspection.
WlCll
❑Yes KN.
1 have mad the haaNnus materials requirements under Chapter 6.95 ofihe Califon
nu Health AreyCade,Sadon 25505,25533 and 25534.1 utbontaW Nu if he Wilding
dohn c filly have ..4 door it u my responsibility m nodi;de,oau�Wl or dm
reqs e orroias.maanc �raPmySignature of Applicant Dale
All roof coverings to be Class"B"or better
Own car authorized agcni Dau g