04100062 (2) CITY OF cuPECONTRACTOR INFORMATION — '
BUILDING DIVISION
sjor+ PERMIT ,,.
BUILDING ADDRESS: THE BUILDING CO PERMITN0.04100062
21610 E
OWNER'SNAME: PERMIT LgUEDATE
ODOM BERRY
E: SANITARY NO. CONTROL NO.
(408) 265-7500
ARCHITECZIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
u10 LICENSED CONTRAC'TOR'S DECLARATION Job Description
U 1 hereby affirm that 1 am licensed under proviuom of Chapter 9(commencing
with Section 700x0.(Division 3af Nc Qusiness and Professions Code.and my license is
in " andyzq-2 z 9 BATHROOM REMODEL (3)
Liccnf q"ATDAAAAl rp_2Mlre
'\1RATION
undITe rcenrds
JyU
3O G Licenced Professional
g OWNER-BUILDER DECLARATION
.�n o I hereby reaso ,('firm on 1 1. exempt from the Contractors License Law for the
p O (allowing meson,Permit
t 7Instr euinesa and Profdcour Code:Any city as county
K$ which myuints a pumit m cnnswet,alma imfor such
h omni m repair any suucmm
Lzr Prior us its issuance.alum require the applicant for such penniuo file asigmdsmmment -
r< that he is licensed pursuanttathcprovisionsoftheContracum'sLicenselaw(Chep¢r9 Sq.Ft. Floor Area Valuation
X=,
l-� (commencing with Section 7")of Division 3 of the Business and Profession Code)or
— that he Is exempt thcmfmm and she buis for the alleged csempuon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of 34YNd,0j Acr00 Occupancy Type
not mom Nan fist hundred dollars(S!RXy.
❑I.uowner of the propcny,mmy employees with wgeuthc'u stile compensation,
will do the work anti the aw<wrt is ootimm�ded oro@rW tonal.(Sec.7044,Business
and Professions Cadc:The Contractor's License Law docs not apply to an owner of Required Inspections -
propany who buildsarimprow thernn,anti whodoeasucM1 wok himmlfar Mough his -
own employees,provided that such improvements art not intended or offered for sale.IL
however.the illban he orimpmvemenng .1be idno, year of completion,theowner. rl�� (, [A �l
builder will have the WNcn of proving Nat he did not Wild or improve for puryos:of ftF �q�Vltll!//,p=p.Ytltat�l
sloe).
❑1,as owner of the property,am eulusinly contracting with licensed contractors to
consumer the projen(Sec.704[4.Business and Prefesions Code:)The Conuictors U. ��� 20 5
cense law does not apply m an owner ofpropeny who builds or improve thereon,and23
who contracts for such projects with a conuacmr(a)licensed pursuant m the Conmecmrs ,
License law.
❑ 1 em exempt under Sec. B&P C for Nis rtuon tap II rs 8 rs ®�IRts rr
Owner Data �(lt��JJ\U nn11� Ifpp��pryJ
WORKER'S COMPENSATION DECLARATION
I hereby af0rm under penalty of perjury one of the following declarations:
haw and will maintain aCcrufcam of Content to uif-homm for WorkersComper-
ration.w provided for by Section 7700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 se baand will maintain Workees Compensation luurana.as mounted by Section
37W of the labor Cade.for the performame of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
mcr: YMF �l ns0 Policy ftiiR�`a 2�—OfklO aJss
CERTIFICATE OF EXEMPTION F1IOM ORKERS'
COMPENSATION INSURANCE
(Thu ase lion need not h.eomplewd if the Permit Is(orotic hundred doliam($100)
ser loss)
I ccnify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to boeome subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of the LaMar Code,you must
Z fotowith comply with such provuiom or this permit shall he deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
P� Ihereby affirm that there is a convection lending agency for me Performance of
C thc work for which Nis permit Is issued(Sec.3091,Civ.C.1
W Q lender's Name
G Lenders Address
U Q I ccnify that 1 ban mad this applichu m and sus:that tW above i"formauun is
L,i P cortex I agree in comply with all city and county ondinamas and state laws relating to
0U building construction,and hereby auhorim representatives or this city to crier upon the
Y' abovcmentioned property for reelection pugmses
0. (We)agree to save,indemnify and keep harnlem the City of Cupertino against
fq liabilhicajudgments,casts and expenses which may in any way accrtm against mid City
V z APPLICANTeUNDERSTANDStAs per ILL COMPLY WITH ALL NON-POINT Issued by: Date' l
SOURCE REGULATII S.
171 . /By�oy Re-roofs
Signature 2G phcarvcmurlcuor am
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will dm appiicvn or future Wilding occuPsat store or handle hevan ous material
ka dcfin.d by the Cuyenino Municipal Code.Chapter 9.13,and the Health and Safety
Code.SeeE]Y. RNu uon 255)3(,)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hevardaus air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection. - -
7nia�alLh&SgctyC�,�b
ie"
❑Yes t&NU
I haw mad the harzNousmatcrialsrequircments under Chapter 6.95 of the Califon
M505.M513and25534.Iundcrsandthxtifthe Wilding
rotcumndy haveatenmth u mymsporttimoymamoythe«cupamof"nimments whlrntem � rwia,canc ar accrdre,te of acapa.y. Signature Qf Applicant Date
2r r All roof coverings to be Class "B"or better
nero -.doom Date