04020143 (3) CITY OFCUPERTINO
BUILDING DIVISION PERMIT %CONTRA'GT,0RINFORMA',' ION
BUILDING ADDRESS: ABCO CONST """"04020143
ER'S NAME: PERMIT ISSUE DATE
NE:CU SANITARY tTO7. i N OL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S p DECLARATION - IOb De$Crl
I touchy affirm Nn 1 am licensed unJer previsions ofCMpmr Y(commencing .n W tl
with Section 7")of Division 3 ofJm BuV.and Profession.Code.and my]I--is
"gym imfull fore oand eDea DEMO THE EXIST. HOUSE
;a= LkemeCla iJeg APR 20 2004
ZipW7 Dalc Contractor
ARCHITECTS DECLARATION
I understand my plans al he used a public mrnrds y g p[
3 0 Licensed Professional
BUILDING
OWNER BUILDER DECLARATION
qy 1 lurch,mage alEfm Nat 11. cBusin from the Conlnnufs License Law for my
i00
which requires
egooi 70nsumer Business and vefmsinm Code:Any city armoury
which rcquims•permit m cnmwcL alone,improve,dcmnlish,or repair any slmcwrt
�zy print m its issuance.also nepows theapplicant for such Permit m file aligned sommmt
< thathcislimnsedpursuenrrorhepmvisiomOftheConuacmr'sLicenselaw(CAaper9 Sq.F[. Floor Area Valu non
(cemmcncingwith Scction7000)dDivision3Oflhe Busim and PmfessionsCde)or
Net he Is axempt IWmfrom and the buss for the alleged exemption.My violW on of -wmirrwTr�A,
Section 7031.5 by any applicant for a Permit the applicant m a civil penalty Of 3 M L O,Cl"gr0 0 Occupancy Type
not tort than five hundred dollar(5500).
I,as owner urge property.a my employees'with wages ss their cele compewtion.
will do the work.and the structure is Out ntended Or offered for sale(Sea 7(al Business Required Inspections
and ProfrstiaTV,m Code:Tcone.License law does not apply m an Owner of q p
progeny who builN or improves thereon,and whodoessuch work himself arhrough his
own employees,provided doggish improvements arc not intended orolferd ferule.IL
however,the building or improvement is sold within one)ear of eemplction.the owner
builder will have the burden of proving that he did Out build or Improve for purpose of
ale).
Owner of tip property am melusiwly contracting with licensed contraemn b
,met the pmjcct(Sec.7044,Business and Professions Code:)The Conuacuir's Li.
me law docs not apply or an owner of pmpeny who builds or improves Merton,and,
who contracts for such pmjccu with a mntrector(s)licensed pursuant w the Conuacmrs
License raw,
lammemp under See ,B&PCf thisrt
It Data
ORKER'S COMPENSATION DECLARATION
I bereby trm under penalty of perjury one of Ne-f 6 dec'land o u:
ve and I maintain a Certificate of Consent to self-insure for WorkefsCompen-
ation,as pro hied far by Section 3700 of the later Code,for the life---of the
We
for which this permit is issued.
I have and will maintain Wakces Compeo stion Ivunna,as required by Section
37W of the labor Code.for rbc performance of On work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(Th6 section need not W eompletd if the permit Is intone hundred di($10)7
or km)
1 certify that in Ne performance of floc work fm which this Permit u issued.l shall not
employ any person in any manner w a m become subject to the Workeri Compensation
taws of California.Data
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should
bcmme subject in the Wohces Compensation provision.of the L i Wr Code,you in=
�Z, foMwith comply with such provisions or this permit that)W deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
(r IWmhyaffnm Na then I,.construction lcndingagcnry ror tW pcffurmenec of
C s7 the work for which this permit is good(Sec.309?,Civ.C.)
{LlQ lender's Name
C Lender's Address
U0 1 certify that 1 have read this application and nate ft,the.love inrmmati-is
{s. p coned.l agree in comply with all city and county oNin noes and some laws totaling to
> CW Wilding construction,
1.goc.crebyaify and mpmsemaivm of City city to cnmfupon tho
r{S.1 .hove-memiond Property for impaction purpuras l
t—'0. (We)age¢In saw,indemnify and keep harmless ala City of Cupcnino eSaimt
TA Iiabilitia.judgments,costs and cxpstraw which may in any way accnm against aid City
U z in cc nee of the granting of this permit Date
^� APPLI NT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINf_ Issued by:
SOUR E ULATIONS.
IfA �n Re-roofs
gone APplic.ra Comranror Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the applicant or future buildinlld"cupant.tort Or handle haardom mamrial
u def by the Cupertino Monte 'Code,Chapter 9.12.and Jon Hcalth and Safety
Scctim zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yon Na
will the apPlimr or ms a Wilding by ft a use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it hanrdna air conamimnu u Ucfined by Um Bay Area AicOuality Managcmcm all new materials for inspection.
Dyes
Ihewaj Nebwafdousma immntsunder .Chapmr695ofthe Celifor
nice Hca W&Safety Cada Smtiom 25505.25533 ad 25534.1 udersond thuifthc Wilding
does Out currently hart a WmmL tha it IS my responsibility m notify the occupant of the
requicnuwichmustCcmmpriurp
Owuthocd agent issuanceof.Ccnlfmamofacu cy� j natureofApplicant Date
Dam All roof coverings to be Class"B" or better
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