00060080 (4) CI'T'Y OF CUPERTINO '�-'_ A,,eq :z " % +^'' •' +h '�` '"'*+
BUILDING DIVISION PERMIT "CONTRACTOR4NEORMATION �
BUILDING ADDRESS: PERMIT N0.
OWNER'S A . JGH�iPERMIf L`'S
RTCHARD ANP
NE:
SANITARY GNTRGL NO.
ARCH=IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±Oo LICENSED CONTRACTOR'S DECLARATION JobDescri tion
u I hereby affirm that I am Merced under provisions of Chapter 9(communing p
with Section?")of DIA.Ma 3.1'the Business and Professions Code.and my license is
in full rola and effen.
qzanreaw
DContractor REMODEL
Dam CUnt.clor
gg ARCNTIELTS DECLARATION
I8'< 1 uMcnunJ my piss shall W used an public rearde
;um t, Liemsed Professional
5 OWNER-BUILDER DECLARATION
i hereby arum Net I am exempt from the Cnneecrora License Law for IW
o O following mason.(Section 7031.3,Bd imsu;and Professiolu Code:Any city.1 c.only t/
e$ which requires a Permit to ennstruct,alter,improw,demolloh,or repair any structure
UZw prior ll)its iatumcc.also m9vire9 the applicant for such permit to file a signed slammenl
a–s< Net he is licensed pursuant to the provisions of the Contractor'sLicensc Law(Chapter 9 Sq.Ft. Floor Area V �tIon
jF$ (commencing with Section 9000)of Division 3ofthe Business and Pr.ressionsCode)or $Ila dM
tion
he is exempt Meet,..and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Penn][subjects Ne applicant to a civil Penalty of 3�'a� 79�r00 Occupancy Type
not more Nen five hundred della.(5500).
❑I.ss awncr of the propeny.mmy employcu with wegesss their sole eompenull.n,
willd.Newark.and Neswnure is not intended or offered formic(Sec.7061.Business 101 - FOUNDPI$AWid Inspections
ind Professions Code:The Contractors License Law does not apply to an owner of
property,who buildwrimprows thereon,and who dasauehworkhimselfortbrough his .. .102 – PIERS
own employees,provided mal such improvements are not intended woffend torula If. 103 – LIFER
however,Ne Wilding or improvement B sold within one year of Completion.Ne owner-
Wilder will have the burden of proving that he did not Wild.r improve for purpose of 104 - REBAR
u10.
❑1,as owner of Me property.am exclusively contracting wit licensed eontncton to 105 — ANCHOR BOLTS
Construct the prejen(Sam.TW,Business and Professions Cade:)The Contncmri u- 106 — SEWER & WATER
al.e taw does not apply to on owner of property was Wilds or improves theran.attd, 2O2 — UNDERFLOOR PLUMBING
who Contracts for such projects with a anuactm(s)licensed pursuant to the Cominal rs
License law. 203 - UNDERFLOOR MECHANICAL
❑lamcumptunder Sce .B&PCfm Nis,mon
204 - UNDERFLOOR FRAME
owner WORKEse'S COMPENSATIONDECLARAnoN 205 — UNDERFLOOR INSULATION
I hereby affirm under penalty of 16.10.of the following deo—throse 301 - ROUGH PLUMBING
7337M.17
has and will maim...artiruam.(coram to self-iomme forworkerscompen- 302 – TUB & OR SHOWER
n,ss provided for by Section 3700 of the LW,code.par the petrm,n ecce of the 3 03 - ROUGH MECHANICAL
for which this permit is issued.
haw and will maintain Workers Compensation Insunna,m required by Section 3 04 - ROUGH ELECTRICAL
Ne laborCade,for Ne performance ofNe work for which Mia permit is issued. 305 – FRAME
Workers Compensation Insurance carrier end Policy number em: 306 – HOLDOWNS
ier: Polity No.:
CERTIFICATE OF EXEM MON FROM WORKERS' 307 – INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(This auction bond not soamplemd If Permit is for me hundred dollars(51(10) 309 - EXTERIOR LATH
or less.)
–' I comfy that in Ne performance Orme work for which this permit 0 issued.I shell nut 310 - INTERIOR- LATH
employ any person In any mannerso as m become subject to the WOrkon'Coutfe"200n 311 — SCRATCH COAT
Laws of California.Due
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should 501. - FINAL ELECTRICAL ENERGY
become subject to the Workers Compensation provisions of Ne Later Code,you most
�'Z rurthwah comply with such Provision.or this permit an.]]W Junod revoked. 502 — FINAL PLUMBING ENERGY
?O CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(hereby affirm Net More is construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
x 9 me work for which this permit is issued(Sec.3097,Co.C.)
ip LendersNune 505 - FINAL ELECTRICAL
Lenders Address
L)Z 506 - GAS TEST
J 0 1 ttNfe Net 1 haw reed this application and sum Nn Nc mow infmmauon is
F builds.1 agree ct comply with..city and county ordinances and sus bova mining m 507 — FINAL PLUMBING
sj U building construction,and hereby authorise rePrtsenmives of this city no cola upon the FIN MEC CAL
W above-mentioned properly for inaNction purposes
(We)agree to saw,indemnify and kap homeless the City of Cupcnino against Q 9 FI
r N 0abilitiu.judgments.e.sts and expenses which may in any way amuse against said City 5 NG
of Me graraft of this peornit.
J APPLII. ICCANTeUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date
SOURCE REGULATIONS.
Re-roofs 516 NAL BUILDING
Signature of ApplicantoConuact., Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant am at handle harudous manurial
u def bed by Ne Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code,Section 35533(1)? All roofs shall be inspected prior to any roofing material being installed.
Oyes ON.
Will the applicant or future building occupant use equipment or dcvio s which If a roof is installed without first obtaining an inspection,I agree to remove
-.nit haxa dons air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 0N
1 hew bad the hntobes materiels requirements under Chapter 695 of the Califor-
nia He.]"Safety Code,Secliuns 355115,25533 end 35534.1 undersand Nu if the Wilding
does not currently have a tenant.that it is my responsibility m notify the moupunt of do
mqulrcnrcnu which must be mel Out issumec of Certificate of occupancy. Signature Of Applicant Date
Owner mautharimd agent Dam All roof coverings to be Class "B"or better
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