02090168 (2) / ilON17:
ITY OF CUPFRTINO - s >ir -�
BUILDING DIVISION PERMIT CONTRACTORINF,ORMATION �,
lTIOG7013 SUGHNSON AVE. FERMA CORPORATION PERMITS(02090168
bN60N LIN 1265 MONTECITO AVE APPLICATI819MIITy 2002
650 961-2742 SANITARY NO. // `` // CONTROL NO.
ARCHITECTIENGINEER: BUILDING P17RMIT INFO
B0LDG ELECT PLUMB MECH
0 0 0
00 LICENSED CONTRACTOR'S DECLARABION
q 1 hemhy allifm that If.licensed audit,IF..co one of Chapmr q(commencing DEMO Job Description
Sad whin SeednnTXXMOI'Division Sof Ne Businessand Profusions Codeund my liaenmis
Ml ull litrm.al cllcci.
License Clan Lie.M
F?
r� Date Contractor
ARC]I1lTeCTS DECLARATION
< 1 understand of,plans,hedI M used as public records
to
a.
FLLOt; Licensed Prumssiowl
y S OWNER-BUILDER DECLARATION
e8 a p 1 hereby affirm that 1 am exempt from Court ContrLiectow Law for the C a 900
,,F00 following Mason.(Section 7031.5,Business and Professions Cole:Any city or county f` Y
u$ which acquires a permit to construct, lw,.impmme demolish,or tired,any should. V
FZy pnnno its issuance.also requires the applicant for such Permit o file a signed statement
ss<
that he is licensed pursuant to the previsions of NeContractor's License Law(Chapter 9 '31' .ffalltba.Al6� Valuation
F$ (commencing with Section WHO of Division 3 of the Businessand Professions Coale)or
— Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than five hundred dollars($500). A Occupancy Type
❑ I.m owner of the property,Of my employees with wages a their sole compensation,
will Jo the work,and the structure is not intended or offered for sale(Sec.70,14,Business
and Pmfessinns Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work hia or through his
own employees,provided that such improvements arc not intended or offered for sale.If,
however,to building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Nat he did nos build or improve for purpose of
sal .).
as owner of the Property.am exclusively contracting with licensed contraction to
construct the project(Sec.7fW4,Business and Professions Code:)The Contractors Li.
entre Law dices not apply to as owner of proper who builds or improves thereon,end
who c4�w
torojecm wit a contractor(a)heiread pursuant the Contractors
License
I
ec. .B&PC fortisDa gg `O— OS SAO DECLARATION
nder penalty of perjury one of the fm owing declarations:
I have and will maintain a Cenifcate of Consenuo sel6insum for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which Nis permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wmkcr's Compensation Insomnce comic,and POI icy number arc:
Cartier: Policy N., _
CERTIFICATE OF EXEMPTION FROM WORKItRS'
COMPENSATION INSURANCE
(This section need not becompleted Rthe Permit is for one hundred dollars o IIXO
m less.)
1 ccnify N4thl
the nuc of tine woh fur which Nis permit is issued.l shall urn
employ anner o mince aohjrgnn4he Wnrkof Compensation
Iw a xr',Cnn m.tion provisions of the LaW,Calc.you mus,
Ofnrmwim previsions or this permit shall M deemed revoked
z CONSTRUCTION LENDING AGENCY
[-+ � I hereby alirm Nat there is a construction lending agency for the performance of
athe work lar which this permit is issued(Sec.300.Civ.C.)
IIJ4, Q Lender's
0, lender's Addms,
V 0 1 ccnify Nut 1 have read this application and slam that the above information is
f1. F building.Iogmc In comply
LGst a with all city
and county
ordinances and stem laws r ngto
OU building enn,and hereby aNrepresentativesives of this city menus,upon het
above-mentionedpro ((it inspection
(We)agree to save,indemnify and keep hirmless
the City of Cupenst s against
wF,aZIiaemese,. ofturn,m he ,manJof in,,expenses which may in anyway,reuse against said City
incomsCAN, of hegfaalipg of thisperm'Q *0/ x�
U z APPLICAN DONS ANDS AND .ILL COMPLY WITH ALL NON-POINT Issued by: at U v
SO S.
d' tat I
tou put c r Date Re-roofs
1AT.ARDOAR000S MATERIALS DISCLOSUR Type of Roof
Will tinder deem orfuwnicibuildingaloe.Chaptsmreor handle l[Icardand atcrial
Safety of ncJ by the upenino Municiral Curie.Chapter 9.12,and she IIceIN and Safety
Jere Section Yt 255321a)? /s All roofs shall be inspected prior to an roofing material beim installed.
❑Yea q.Nn P P Y g g
Will the applicant Or future building occupanlfree equipment nrdeviceswhicb If a roof is installed without first obtaining an inspection, I agree to remove
emit haeardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disarm'I
Yes No
I have red the ha.ulous ntmctials requireemsunderChapw,695olNeCalihv-
niallealthAS Coda,Sections 25505,25533 trod 25534.1 underswnd that if the huilding
Nes not cu nil have a witaxyi Nat it is my responsibility to noti ly the occupant f the
requimmmt ch as El prior In issuance ofa Certificate of cu nby�j
�� 1,- Ignature of Applicant Date
ncr —uvia J ogcm Date All roof coverings to be Class "B" or better