02100049 (2) / -o
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION-—�.
BuIIPd8Bk1gpsW ESTATES DR CHEROKEE CONTRACTING CO. PERMITN®2100049
GWi,W3199:BETH MULLEN 1220 COLEMAN AVE APPLWATTUI/IW2002
da
orONE: 408 727-9850 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION
I hereby Art,.mal l am licensed under pmviary of Chapter 9(commencing �s TTT���T ❑ erWtlpJ1
with Section]I it If Division 3 o be Busincas and FnfcssinnsCodc,andmyliccnse is L 4 LA16iCHL l5.U.
in full Tome and ecce
OZ- Liccn CI a ^ b Lica I �
0�- Dan O L TSDEo Get- /
F- ARCHITECTS DECLARATION �J
o� I understand my plans But he,used as public..,or
ihLicensed Professional \tV,]
y OWNER-BUILDER BUILDER UECe Comm ON
z 8<f 1 hereby affirm that I oto exempt from the Convenors License Law for clic s $1000
ec
as m0 following mason.(Stion7031.5.Business and Pmfvaions Code:Any city Or county i
a�$ which.quires a permit ,,construct.alti,imp row.demolish,nr repair any slruGmre
prior to its issuance,also requires she applicant for such permit to file a signed statement
that he is licensed pursuant o she provisions nfthe Contractor's License Law(Chapter 9 39&3.3�0"b6AI@A Valuation
d�0 (commencing with Section 70(f)or Division 3 of the Business and Professions Code)or
$ mat he is exempt themfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Wordy,of PN-N Occupancy Type
not more than rise hundred dnna.oNBo). 202 - UNDERFLOOR PLUMBING
❑I,as owner of the property,or my employees with wages as their role compensation, 3e± RE)USH
will do the work,and the slrucWR is not intended or offered for sale(Sec.70,14,Business
and Professions Code:The Commucsors License Law does not apply in an Owner of 302 - TUB & �(jU}ff wf�tions
property who builds or improves Hereon,and who does such work himself or through his
own employees,provided that such improvements an not intended oroRered for sale.If. 502 - FINAL PLUMBING ENERGY
however,the building or improvement is sold within one year of completion,the owner.
buildSO6 - GAS TEST
builder will have the burden of proving mat he did not build or improve for purpose of
sale')' 507 - FINAL PLUMBING
❑1,as owner of the property,am exclusively contacting wit licensed comments to
convect the project(Sec.7044,Business and Professions Code:)The Comism ori Li.
cense Law Jas not apply to an owner of property who Wilds or improves Lemon.and
who contracts for such projects with a contaesor(s)licensed pursuant o she Contractor's
License Law.
Cl I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby e1Trm under penalty of perjury one of the following declarations:
1 have and will maintain a Cenificau,of Consent to self insum for Worker's Compen-
satioq as provided for by Section 3700 of the labor Code,for the perfomurc,of the
work for which this permit is issued.
C] I have and will maintain Worker's Compensation Insurance,as required by Section
3AN of me LatiRom Cmde,for Use�pelrformmce of the work for which this permit issiissued.
My
mnce
1 Camerr6'rILT'tA�ssa�linn InsulAL`utj te,t,pe/fiycy No.:UA 6!5 /
CERTIFICATE OF EXEMtefRiON FROM W ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if she permit is fnrnne hundred dollars(SIM)
m loss.)
I certify tet in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so v to become subject o the Workers'Comper ation
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccr i(cate of Exemption,you should
become subject to she Worker's Compensation provisions of the Ichor Code,you must
O O forthwith comply with such provisionsor tois prni,shall tc deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(r .N+ I botchy affirm that tore is a construninn lending agency fanhe Performance of
Ix 7 the work for which this Permit is issued(Sce.30M.Civ,C.)
QLcndcr'a Nemc
7 z lenders Address
U 0 1 CRIRy that I have Rad this application and style that the aWvc infnmmllnn Is
^F correct.I agree to comply with all city and county ordinances and sum laws relating to
O U building construction,and hereby authorim representatives of this city to emir upon the
above-mentioned property,for inspection purposes.
(We-)agree to save,indemnify no keep harmless the City of Cupenion against
1A liabilities,judgments.costs and expenses which may in any way acerae against said City
U z in consequence of to granting of this permit.
r-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
ECU TIONS.
QT 16 ]. Re-roofs
Signamrc of Applic-ant/Contractor OU Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant nr furore building occupant
pttramor handle Health and
as define)by the Cupertino Municipal Code,Chapter 9.11,and the Hcahh and Safety �
nde,Seerot25531(a)'r, All roofs shall be inspected prior to any roofing material being installed.
❑res Q F/
Will tcapplicant orfuwrcbuilding Occupant me,equipmemordevices which If a roof is installed without first obtaining an inspection, I agree to remove
mit he..does air contaminants defined by the Bay Arca Air Quality Management all new materials for inspection.
Distrin7
Yes
I have read to hanrdous materialsrequirementsunder Chapter 695 of the Califor-
niaHcalth&SofclyCWe.Sadmu15505,75533and755M.1unMrsmndtelifthe building
does nal cumendy hart a mvm,their is ney responsibility m nndfy die oxopint m the
m mcnts which satMmet pito iemance ofa CeriReme of Occupancy Signature of Applicant Date
t' All roof coverings to be Class"B" or better
Owner or amhodacd agent Date