03120085 (4) CITY OF CUPERTINO 'f "' 71 �^. "',� 'p'�k�j t/�`*T -
BUILDING DIVISION - PERMIT CQNTRACTOIR*� ,ORMXT16N. '
BU ILDING ADDRESS: ANDREW STACK PERMIT N0.03120085
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O o - LICENSED CONTRACTOR'S DECLARATION L� O O O
uF 1 hereby affirm that I am licensed under previsions or Chapter 9(commencing - Job Description
Zra, with Section7MO)of Division 3orthe Business and Professions Code.and my license is
^1 5; in full fowe and effect.
Ji2z Lieea,ecla,a Lm.a BATHROOM REMODEL--HOT MUP TILE SHOWER
4FO Dam Cuntmcmr
ARCHITECYS DECLARATION
y C 1 understand my plana shall he used as public records
JyU
Soy Licensed Pmfessionei
g OWNER-BUILDER DECLARATION
aS I hereby affirm that I 1 exempt from the Contractor's Co :License Law for the
tSO followwhich ingocitionuiresa errant AULS,Business and improve,
demolish.
Code:Any city or county
k$ which requires a issuance,
to construct,alma improve,demolish,ore.repair anygned structure
thither itscensed pursuant
the
to the ovisio sof for such Permit mfiense Law stalemate
that mencingwitpSectio 70M)ofDivision
ivionn3oftthe Cmrtmcwr'andProflzw(Chapter 9odc)or Sq.Ft. Floor Area Valuation
(CoJ}�C that he s exempt
and)fee iuli for
m theegeBusiness mpton.Anyae Cale)or
xi Nat he u ex1.5 b sanwfrom and Ne Luis for be alleged exemption.Any violation of rA,ya ATa.,w,Ia
act orethanShyaundreddoll rmapertntlsubjectsNeapplicanttoaCivil Finally of 3�aDN241] ge100 Occupancy Type
nal more than fm hundred donors SSM). P Y YP
I,to;owner of the property,or my employees with wages u their sole compensation,
will do the work,and the anent.is oat intended or offered for$ale(Sec.7W.Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
prapeny who builds orimprows themon.and who doe,such workare himselfmr through his C' a� ��®
own employees,provided Nat such improvements nos intended oroRered formic.if, r grl,
however.the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or improve for purpose of
FEB.2 3 2004
❑1,ea..at of Ne property,am exclusively contracting with licensed contractors to
Construct the proj I(See.70M,Business and Professions Code:)The Contractors Li.
came law decor lepply to an owner o(pmpeny who builds arimprovu Ne¢an,and BUILDING who cornmets fora h pmjecm with a comm�or(s)licensed pursuant to the Convectors LD
Li se w
I a a mptun Se B&PC for this reason
Owner����DeJJ�F r
OR R' CO PENSATION DECLARAFON�
I hereby alarm under penalty of perjury one of she following declarations:
1 haw and will maintain aCenilerin a(Comenno selr-insure for Workers Compcn-
sation,at provided for by Section 3700 of the Labor Code,for the Performance of the
work for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,an required by Sectio
37M of Ne Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This acctian need not he completed irlhe permit is formic hundred dollars(SIM)
or less.)
1 certify on,
in the fierfommnce of the work for which this Permit is issued,1 shall not
employ any person in any manner se as to become subject o the WorkersCompensation
Iowa mf California.DON
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Cade,you must
O forthwith comply with such provisions or Nis Fermitshall he deemed revoked.
'zCONSTRUCTION LENDING AGENCY
'I+ ��+ I hereby affirm Nat there is a construction lending agency for Ne performance of
ai the work fur which this pmmil is issued(Sec.3097,Co.C.)
W� Q Lender's Name
Z Lender's Address
V Q 1 comfy Net 1 tare read this application and show that the above information is
Iy F correct I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby lotteries reposemadws of this city to enter upon the
aabove-mentioned prapenyfor
robt and
exposes purpose. _
r� (We)8gabc to saw,indemnify and keep hamdeas the City of Coleco firm against t
N inccili ;judgments,crmaindexpenxcarmit. may in any wayaccmc againsluitl City /
C),'� m co uenee o c greening of this permit.
^t APP I ANTU R TAND ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
s0 GU A 0 S!
SRe-roofs
gMmre ofA icanUConlracwr - Dam
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will the applicant or future building eccupoin"wre or Ic ha'rutlous mawtlal
as defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)?
F7 year All roofs shall be inspected prior to any roofing material being installed.
Nu
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicam orfufufCbuilding=upon(use equipment or devices which P g
it hazaNnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
tDwict?❑YesNu
have res a hoomous me criers requirements under Chapter 6.95 of the Califon
Heulth6Saret oda.Sectou 05,25533 and 25534.1 undersmnd@w iftho buildings no mcnlly t w r terra t a u u my rtsponsiM1ility m noul'y the rccupant of Ne
ui inrhic ms cmep witta.mnracemfitaw�,cpc,Pn—to Signature of Applicant - Date
nc sura thmixe asent ((GG. All roof coverings to be Class „B.' or better