05010084 (4) CITY OF CUPEwrINO z +^`"�€*, fix - '•� . ' ;�„`" 'a/� 'p' yr""
HUDAING.DIVISION PERMIT
?s'CRACTC)R�INF�Q MATION.,
BUILDING ADDRESS: FIRST BAPTIST CHRUCH CUPER T4fIC)No05010084
19515 HOWARD CT
OWNER'S NAME: PERMU ISSUE DATE
FIRST BAPTIST CHRUCH CUPER IN019515 HOWARD CT. 01Z13/2005
SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIEC! PLUMB MECH
+oma LICENSED CONTRACTOR under
DECLARATION
f O I ion? (firm)hal l am licensed under sof Chapter 9 my licenses Job Description
to r. Pramxmm v s P
i with Scuion](M10)of Division Sof the Busirrcns and Professions Code,and my license is ,
>>„ imfall Rlmaandeffect. ELECT-OUTDOOR BOX .W/PVI Tp
a Y License ClassLic./ I@
c p Da¢ Comhacara
fwj ARCIIITECTS DECLARATION
C w U I understand my plans shall W used as public records FFR eo„ Li..dProfessional FFR g' 2005
OWNER-BUILDER DECLARATION
ay 1 hereby affirm that I am exempt from the Contractors License Law for the
000 following mason.(Section 7031.5.Business and Professions Code:Any city or county p 8 200 0 O
m LL which requires a permit to construct,eller,improve,demolish,or repair any structure p ri
poor it)its issuaocc.also mquira the applicant for such Permit to file a signed statementqq
;Ea that he is li<cnud Pursoanuolhc provisions of the Cnntmcar's Liccnu law(Chapmr9 STI. Ft. FloorArea Y e v21Ua110n
Fp (commencing with Section 7")of Division)ofthe Busincssanl Professions Care)or
3$ that he is exempt thcmfrom and do bazis for the alleged exemption.Any vinlation of
Section]011.5 by any applicant for a permit subjects the applicant o a civil Penalty ofor Occupancy Type
ym mom man five hundred dollars(s5BB). - PanC Y YP
I,az owner of the property,or my employees with wages as their sole compensation,
will do he work.and the swaum is not intended or offered for sale(See 7014,Business Required Inspections
and Professions Code:The Contnntnsor's License Law docs not apply to an owner of 9 p
property who builds or improves thereon,and who does such work himself or Brough his
awn employees,provided that such improvements are not intended or offered for sale.If.
haw er,the building or improvement is sold within ane year of completion.the owner-
bullet will bare the burden of proving that he did not Wild or improve for purpose of
sale.).
❑ I.as owner of the property,am exclusively contracting with licensed contractors to
oniwet the project(See.7044.Business and Proressians Cade:)The Contractor's Li.
cense law docs not apply to an owner of property who W ids or improves demon,and
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor's
nu law.
I Traunder ,B&P�C for mix mason
O�
WORK ER'S COM PENITAtION DECLARATIO
1 hereby off under penalty of perjury one of the follow) g declarations: ,
1 have and will maintain a Certificate of Consent to self-insum for Worker's Compere
sation,an provided for by Section 37W of de labor Code,Or the performance of the
work for which this fnrmit is issued.
1 bare and will maintain Worker's Compensation Insurance,u myuired by Section
17W of de LAW,Code.for the performance.(the work for which this Permit is issued.
My Workers Compensation Insurana crier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EX EMP(ION FROM WORKERS'
COMPENSATION INSURANCE
., (Thu section need not W completed if the Permit is Roane hundred dollars($100)
less.)
I certify Nat in the per firs a of he work for which this permit is la tied.l shall mol
employ any person in any cr m as les Wcumc subjen to the Workuri Compensation
Laws of CIIIf al
Applic� after ma should
NOTIC TO LI :If. far making s Ccnificnc of Exemption,you
Cecom[p5 t to the Worker's Com Pcnsadnn provisions or the Labor Code,you must
�,Z mrma,itt comply with such provisions or his Permit shall be deemed revoked. ,
Z O CONSTRUCTION LENDING AGENCY
1 hominy alTrm that dere is a Commoti nn lending agency for IW Performance of
D: do work for which this Permit is issued(Sec.AMYL,Ci,C.)
4 � lender's Name
1' lender's Addreu
� z
J Q 1 certify that 1 have rod thisapplication
and coon and Bute that and
above information is
1 F" cordon.I agree m comply with all city and county ordinances of and state laws r upon
to
�U buctoe-ncotnned proandhcrcnyauthorimrpomsentatives of this city Cor enter upon the
about-mentioned to save forinspection keepha
WC)agree to saves indemnify and which
harmless de City of against against
Z
liabilities,judgments,
en.nond expenses which may in any way accrue against said City
of
.J Z, APPLIC N'r UNDERSTANDStANDrWILL COMPLY WITH ALL NON-POINT Issued by: Date d
S EGUL0 5.
`) `�5 Re-roofs
)VAnbre or Applicam/conracmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will oc applicant tar future building occupantsmrc or haydlc harardous maunal
As defined by the Cupertino Municipal Code.Chaps=d do Health and Safety
Cale.S'c❑c ye 15513(x)? , All roofs shall be inspected prior to any roofing material being installed.
Yes
Will thea applicant or fuart buildin nears am use If a roof is installed without first obtaining an inspection,I agree to remove
rap 6 p equip Marta which g
tics' as Air aonmminantsazdefined by me Bay Arca Air Quality Management all new materials for In$peCIlOU.
Diuric?
❑Yes pi No
I have mad the bantams materials requirements under Chapter 695 more Califor.
nia Hcold&Safety Code.Secuons 25505.35511 and 35511.1 undersand hat if the building
Jars cumandy have a bra a it is my sponsihility les noury tW t nupanl of IW
airs naWhirn a mirOx c raccruBeamnfaeupa^cy. Signature of Applicant Date
/ )-19- All roof coverings to be Class "B"or better
owner" odaed agent Dale g