02100200 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CQNTRACTORJNFORMATION
BUI 1 RE AV RJ ELECTRIC PERMITN®2100200
GWR)kl,[h]IIEGONTERMAN 6003 MONTORO DR APPLICAT)P19S 13�T 2002
ONE: (408) 281-3337 SANITARY NO. CONTROL NO.
ARCHITEC AINGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
w00 LICENSED CONTRACTOR'S DECLARATION
<U s: I hereby affirm that I am licensed under provisions of Chapter 9(commencing ELECT SERVICE •MfMV On
�< with Secdnn70(0)af Divigyn(�f me Ousixuand Profcuiow Cak,and mylicenm is
La!Ain full forte and effect, ff33
ZOnc5 License Clam�(_Lic.N�t�[�,��
2 m� O Use Contractor
ARCHITECTS DECLARATION
Q < 1 understand my plans shall W used as public records
a
3 w
Licensed Pmfcssi.nal
C Wy O
OWNER-BUILDER fr DGCe Contractor's
ON
8 00 1 herchy affirm than 11. exempt from the Cssionsm's License Law for the $2000
w 00 (allowing rums a erritnt ]1131.9.Business and ve,de i demolish.
Code:Any city m county
u which rcyuires a petsnil re uinnru0.niter,int L ave,demolish, fi roam,n d spacr cat
prior to its issuance,al.en requires me applicant lar such permit file&sign ed stammers a�f oorrenss-a
q�Z<
that he is licensed pursuant to the provisions ofmi,Contractor's License Law(Chapscr9 3$q6 L+tPIWCDOY .AaQ Valuation
a�F� (nrmmcncing with Section 7000)nI'Division 3nf the Business and Professions C.de)or
that he is exempt therefrom ad the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicatfor a permit subjects the applicant to a civil penally of PNN OCCU anC e
not marc than five hundred dollars($5011). 304 - ROUGH ELECTRICAL
p yTYp
❑I,as owner of the property,or my employees with wages m their ale compensation,
will do the work,an the nmetom is not intended or offered for sale(Sec.7044,Business J_I=—�
and Professions Code:The Contractnri License Law does not apply to an owner of equlre Ift
pmpcny who builds orimproves thereon,and who domauch work himselfor through his
awn employces,pmvidcd ton such improvementsart nut intended oroBered formic.If.
however.me building or improvement is mid within ane year of completion,me owner. APR
gT {T '1 qoo']
builder will love the burden of proving that he did not(wild as improve far purpose of Hr R LI 1 L J
sale.).
❑1.as owner of me property,am exclusively contacting with licensed contactors to BUILDING
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,+
convect hot pmject(Sec.7014.Business antde:)and Protests CoThe Contractor's Lt
cense law does not apply to an owner of pmpeny who Wildroves thereon,
Wilds or impand
who contacts for such pmjecu with a comseclor(O licensed puauant to me Contractor's
License Law.
❑1 as exempt under Sec. .B&P C for mis reamn
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of me following declarations:
1 have and will maintain a Ccnificate of Consent to self insure for Workeri Comport
cation,as provided for by Section 3710 of me labor Code,for the performance of the
W
ork(nr which thispermit is issued.
❑1 have and will maintain Workers Compensation Insummer.as required by Section
3700 of the Labor Code,for the performance of me work for which his Pamir is issued.
My Workcrs Cn pc at inn lnsuance ca icr and Policy number am: t�
Carica: Policy No.:��"/ p
CERTI y A' '0•L'XEM ION FROM WORKE—�S'
COMPENSATION INSURANCE
[This section arilan W complcled if the permll is for one hundred dollars($]M)
.r less.)
I certify tool in the peafmmace of the work Bt,which this permit is issued.1 shell not
employ any person in any manner sit as to become subject to the WorkersComliensalion
Laws of California.Date
Applicant I
NOTICE TO APPLICANT:ll',after making this Certificate of Exempli in,you should
Namara subject to the Worker's Compensation provisions of the labor Code,you must
OO forthwith comply with such provisions nr this permit shall be deemed revoked.
z y CONSTRUCTION LENDING AGENCY
[-� Ihomhy affirm mal mere is aconswction lending agency for the performance of
me.,it for which this permit isissued(Sec.LMP,ON.C.)
0. Q Lender's Name
.Z. z Lcndert Address
U 0 1 comfy Nat I have read this application and stam that me&have information is
U. P coned I apace to comply with all city and county urdinaces and stare laws relating to
C)U Wilding convection,and beteby culhnrire mociamssives of this city to chair upon the
aMve-mentioned property for inspection purposes.
p,
(We)agree m save,indemnify and keep harmless the City of Cupcnino against
F' rA liabilities.judgments,costs and expenses which may in any way arcane against mid City
U z in conscqucnce of the granting of this permit tT1
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ER G LAT NS �]
T Re-roofs
'awrc of ApplicaMCit pact., a Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building aeupat start or handle hsmnfous materiel
m defined by the Cupenino Municipal Care,Chapter 9.13,and the Health and Safety
ctde.Score,zss3xo7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes f�s'u
Will the ePplicam or future Wilding mcupnm use cyvipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hoaoNous air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection.
District/ )
❑Yes Ka ^
Ih& read the heallouss 25505lsreyuirc,12553ndcrderura pan93 nfmb Califoo- I
ria Health&Safctyhawa Sections25505, my responsibility
to no"mndmocculanthe Wilding In''Q rl{II ,7)✓,I+ L, a 3
fres not currently hese a venom,Not it is my resgmsibilily m no"
lM1c cecupat of me
mquiremc sew ' must me pd. rissuaccofaCcnifienmt Occup cy' Signature of Applicant Date
r
'or am agen Date All roof coverings to be Class "B" or better