04050039 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMITCON TRACTOR`fINF�ORMATTON:
BUIL DING ADDRESS: THE WINDOW BROKER PERMIT N8.4050039
O E NA E: PERMITISSUEDATE
E: SANITARY NO. CONTROL NO.
ARCHITECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� t�
moo LICENSED CONTRACTOR'S DECLARATION
m 1 hereby.(Firm that I am licensed under provisions of Chapter 9(commencing Job Descriipatii}on,�fI rI
'iw with Section 70(y))of Division 5 of the Business as�a Pnrcssinn.cnM.,na mrliavc is y y�\UI Q;1 aD
^0y in lullfomea c c / 2, REPLACE WINDOWS s�
t,�i License CI Lk.a
—o Date Ga MAY 11 2004
A CHITECTSDECDECLARATI
I un d my plans shall be uudar3MdC2cnrds
DaU �s n
;Et; LwInsed Professional p�A ft� �
0g OWNER-BUILDER DECLARATION ILY I�JJJ � AN
1 hereby affirm that 1 am exemps fru.Ne Contractors License Law far the
p 0 fallowing reason.(Secuun 7031.5,Business and Pmfesaom Cade:Any city or county
$ which requires a permit to construct,eller.improve,demolish,or repair any structure
Fibprior In its issuance,also requires the applicant for such Permit o rile aligned immanent
that he is licensed Pursuant to the pmenimisof the Contracturi Limn.Live(Charter 9 Sq.Ft. Floor Area Valuation
yreF$ (commencing with Section 7000)of Division 3 of the Business and Profesinm C.Ic)or
.- that he u exempt therefrom and the bussu for the alleged esunplion.Any violation of
Section 7031.5 by any applicantfor a permit objects the applicant o a civil Penalty of 328F$$HtiJf3bE00 anC Occu e
not mom than live hundred dollars(5500). - Occupancy Type
0 I,as owner of dre property,or my employoes with wages as doh sole compensation,
will do tine work,and Ne smacs.e is not intended or offered for sale(Sec.74344.Business
and Professions Cade:The Conhaclor's License Law docs arts apply no an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
..employ..provided 0.1such improvements...or intended m offerW for We If.
bowever.Ne Wilding or improvement is sold within one yeas of completion,the owoer-
W ilder will has the burden of proving that he did not Wild or improve for purpose of
sale.).
0 1,as owner of the pmpcny,am exclusively contracting with liccmed contractors to
construct he project(Sec.701d.Business and Professions Codc:)The Consracmrs V.
cane law does not apply to an owner or property who Wilds or impmves 4smon,and.
who contracts for such projects with a convactor(s)licensed pursuant o the Contractor's
License law.
0 1 am exempt under Sec .B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affimt under penalty of perjury one of the following declarations:
have and will maintain eCerdOam of Conserv to ulFinsurt for Workers Compere
737W
n,n provided for by Section 37W of the Labor Code,for Ne performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as mgmMd by Suction
of the Labor Cade.for the performance of the work for which this permit is issued.
War s penNti��n Imurapce Gamier and Policy number�am'�Pi L!on; camicr dN..:_.( `m.`
'✓ CERTIFICA OF EX OM WORK RS'
COMPENSATION INSURANCE
(Thuuction wed not W eomplemd dine Permit is forom hundred dollars(SIM)
or Ills.)
1 certify has in the urfor nenec of the work for which this Permit is issued.I shall nus
employ any mrpm in any manner so as to become subject to be workers'Compeac adon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Its Ccmificam of Exemption,you should
become subject to One Worker's Compensation provisions of the Labor Code,you must
.JO rothwith comply with such pravisiamrt
or Permit shall be deemed revoked.
Z""' CONSTRUCTION LENDING AGENCY
(,� I hereby affirm that here is a construction lending agency for the Performaim,of
aac work for which his permit is issued(See 309'/,Civ.C.)
Y;� Landers Name
C Lenders Address
U O 1 comity hal I have mad Nis application and some hal he about information is
L,, f' correct.I agree to comply with all city and county ordinances and auto laws relating tu
0(J Wilding construction,and hereby audmtine mimseatafivn of this city so cater Upon he
} U akw-rimmimed property for impection purposes.
(We)agree to save,indemnity and keep loomalces the City of Cupertino against
HIiabilisies.judgmema,costs and expenses which may in any way accrue against said City
L)Z in consequence of the granting of this permit. 'IU IJ
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCER LA ONS.
s — Re-roofs
Slgn rt of ApplicanUConmanor � �.D etc
HAZARDOUS MATERIALS DISCLOSUR `— / Type of Roof
Will he applicant or future Wilding occupant sort os th.undf.4avadifints,material
m defined by the Cupenino Municipal Code.Chapter 9.11,and the Health and Safety
Calc.S❑tYoesn 25532(a)? ICN. All roofs shall be inspected prior to any roofing material being installed.
W
ill the applicant or future building If a roof is installed without first obtaining an inspection,I agree to remove
pp 6 occupant esu equipment or devices which
Lus air conmminanu u dcfincJ by IM Bay Area Air Quality Management all new materials for inspection.
,
s Nu
e mad the h=mi)us materialstcquiremcnu under Chapter 6,95 of the Califor.
Safety Codc,Secd.025505,25533 and 25534.I undcrsmnd hazifhe Wilding
end ho.c a tenant.Naz it u my nespomihifty m nouly do occupant or the /
xw chmu,tbe mat prior to issuance of.Cc ate nrDccapency. Signature of Applicant Date"��'� ts ���� All roof coverings to be Class"B" or better
horirad agent Date