04060236 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CQNTRACT0RINFORMATION:'"
BUILDING ADDRESS: v PERMIT N0b4060236
21408 K OWNER'S NAME: PERMIT ISSUE DATE
BABU NOTT 06/28/2004
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Oct, LICENSED CONTRACTOR'S DECLARATION Job Description
C m 1 hereby affirm that 1 am licensed undro2Vv dons of Chapter 9(commencing p
U wlh section](AMO If sion3oflhe Businesf6hd Plyfessinm Codc,andmylicenu is
candcffe 2&3 3� CEILING LICHTS/WALL .SCANCESyg� )
j Z Lias vl Lk..1 YETHALED
r� Dam c. cam serer CONTRACTOR: NOLASCO CONSTRU -! ARC ITECTSDECLA ON
Y C< I u rsmnd my plans shall W used as public mcortl"
Ny
3u t;; Licensed Professional
o
OWNER-BUILDER DECLARATION A
L I affirm the 1 herehy m Nat I em exempt from Conuacoi License Law for the JAN 12— 1005!
E p o fonnwing mason.(SC,Mm 703 IS,Business and Profmmdons Code-:Any city or county
K m which requires a permit to Construct,a@q improve.demolish,fir repair any Structmo
poor to issuance.also requires theapplicamfor such permit to rile a signed.Statement
that he is licenud pursuant it)the provisions of me Contractor's License law(Chapter 9 Sq. Ft. Floor Area V
ar (commencing wire Section 7")of Division 3 of the Business and Professions Code)Or
y my he u exempt thertfrom and the basis for the alleged eaemph on.Any violation of
Section 703 LS by any applicant for a permit SaMccu me applicant to A Civil Penally Of APN Number Occupancy Type
not more man live hundred dollars(5500).
01,u owner of the propery,or my employees with wages as their Sale compensation, 3620604(] . (]0
will do the work and the swcwre is not intended or offered for sale(Sm.7W,Business
and Profmiom Code:The Contractors License law docs not apply to an owrcs of Required Inspections
property who builds or improve Macon,and who der such work himself or through his
own employees,provided mat such improvements are,not intended or offered for sale.If,
however,me building or improvement is sold within one yea of completion.the owner.
builder will haw the human of proving mat he did not build or improve for purpose of
sok.).
❑1,as owner of the property,am exclusively contracting with licenud contraction;to
construct the project(Sec.7044.Business and Professions Code:)The Convector's Li-
come law docs not apply to an owner of property who WIIds or improves theteen,and
who conmcm for Such pmjec s with a comncta(s)licensed pursuant to me Cormacmra
License La
❑1 am cacmpt under Sec. .B&P C for this seuoa
owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby anise under penalty of perjury ore Of the following dacluatium:
_5 1 have and will maintain aCeNGeste Of Comer m self-insure for Workch Compcn-
ation.as provided for by Section 37M of me Labor Cade,for me performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as accrued by Section
3700 of the labor Code,for the pufortnancc of the work for which this Nabors issued.
My Worker"Coope lie Inwranx atriy and Policy number am:
a J\ 2. Y/�'_a^I Policy NO.:
CERTIFICATE E�NP/riON FROM WORKERS'
COMPENSI INSURANCE
This smtion recd not be completed K tri permit is for Ore hundmA dollars($100)
or less.)
I certify mm in me performance of me work for which this permit is issued,1 shall not
employ any person in any manner SO as to become subject to me WCrkefi Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Coal rate of Exemption,you should
become subject to me Workers Compensation provisions of the Labor Code,you mutt
.J Z forthwith comply with such provisions or this permit Shan W deemed revoked.
zCONSTRUCTION LENDING AGENCY
I hereby affirm mat then is a construction lending agency for the performance of
C the work fur which this permit u issued(Sec.3091.Civ.C.)
irl A Larder's Name
= Z L.cndcr's Address
U Q 1 certify mat I have mad this application and state mat the above information is
L. F-' cortecl.1 agree to Comply with all city and county ordinances and sum laws relating to \
0 U building construction,and hereby aumome rtprescnutivm Of this city to color upon me
r W above-mentioned property for inspection purposes.
t1 (We)agree to save,indemnify and keep harmless the City of Cupertino against
F+ VI liebiyyrdlas.judgmems.costs and expenses which may in anyway accrue against mid City
C.7 Z in colsequcnceofinegrantingofthis permit.
APPLICANTERSTA DS AND WI OMPLY WI ALL NON-POINT Issued by: Dat
4j
- a-roofs
Signature of ApplicanUConuactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or harmdlc hs'/Mous material
as dented by the Cupeni no Municipal Code,Chapter 9.12.and me Hcalm and Safety
Code.Section 255R(a)?
YIN J/� All roofs shall be inspected prior to any roofing material being installed.
❑ ] U
Will the applicant or future buildingaccupom use equipment ordevicm which If a roof is installed without first obtaining an inspection,I agree to remove
.nit herardom in cards., as defined by me Bay Area Air Quality Management all new materials for inspection.
Diairia?
byes
1 have real the havardaus materials requirements under Chapter6.95 Ohne Califar-
niaffc m&Safe-lyCocic,Ssedwr25505.25533and]534.lundcrnvW this if the Willing
d not currently haw a terns mm it is my responsibility m notify Be<upam Of me
requiremc hichm Wmetonorth y'nmaor,cenirst, Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or amhos3md agent Wm