04040078 (2) CITY OF CUPEW11N0t -'" =°S ' "��+
BUILDING DIVISION PERMIT WONTRACTOR INFORMATTON
DUILDING A DDRIiRS: MOCELIN CONSTRUCTION PERM IF NO 04040078
866 LINDA VISTA DR
NAME: PERMIT ISSUE DATE
) IDIT & BARUCH DEUTSCH 1537 RILLI T 004
ONE: SANITARY NO. CONTROL NO.
(408) 732-6655
ARCHITEC(ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:Orr LICENSED CONTRACTOR'S DECLARATION
C 1 hereby affirm that 1 am hothead under previsions of Chapter v(commencing Job Description
n with ScniontflfXq.f Dbjxmn3of the Business and Professions Code,and my license is
inmufameand effect. ADD 28 SQ. FT. REMODEL MS BDRM & BATHRM
5 z License Class.Llc.g
DamContractor.
qq ARCHITECTS DECLARATION
3 1 understand my plans shall W used as public recnNs
:yu
SCG Licensed Prnfessiunal
g OWNER-BUILDER DECLARATION
9�y 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following mason.(Section 7031.5,Business and Pri fesxiuns Code:Any city or county
$ which requires a Permit to construct.alter,imponat,demolish,or repair any structure
-,14000
Zi prior to itsissuance,also requires the applicant for such Permit to File a signed statement
< that he is become!pursuant to the provisions(if the Contractor's License LAW(Chapter 9 S Ft. Flo a ryryry �y^'�^t� Valuation
x�m (mmmeneing with genion JfgNl)of Division Sof the Business and Prufessinnscrxle)ur 9A �r 1 F77- �
i that he is exempt Roefmm and Vic basis for the alleged exemption.Any violation of '1— -\j 1 s I 1 1 t 1
Section 7D31.5 by any applicant for a permit subjects me applicant to a civil penalty of j 33�81614�dflTBeiOOi
not more man Eve hundred dollars($500).
F O cupancy Type
01,As owner or tiro properly,or my employees with wages as their solo compensation,
will do fie work,and the Aman¢is not intended or offered for sale(Sec.7044,Business
and Professions Cade:The Contractor's License Law does not apply to an owner or [1C ire n ecC
tonicity who builds or improves thereon,and who does such work bimselforlhrough his --
awn employees,provided that such improvements are not intended or offered ferrule.If.
however,the building or improvement is sold within one yea of completion,me owner
builder will have the burden of proving that he and not build or improve for purpose of
oto.).
0 I,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Lh
cense law docs not apply to an owner or progeny who Wilds or improvesthemon,and
who contracts for such projects with a conoacmr(s)licensed pursuant to the Commerce&
License Law.
❑1 am exempt under Sec. .B&P C for this rumor
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury m¢of the fallowing declarations:
I have and will mormia a Curti fume of Consent to sel&Insum for Worker's Cumpem
smion,as provldcJ for by Section 37W of the labor Code,for the performance of the
work for which this Permit is issued.
0 I have and will maintain Worker's Compensation Insurance,in required by Section
3700 of NC Labor Caddo.for Ne Performance of the work for which this Permit is issued
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE DP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(phis section need not Meompleted if the permit is for one hundred dollars($IIX)
or less.)
1 ccnify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner sit os to become subject o the Workers'CDmpensation
Law,of C011fmnla.Date
Applicant
NOTICE TO APPLICANT:It,after making this Cedifcam of Exemption,you should
become subject 10 the Worker's Cam pcmation provisions of the Labor Cnde,you must
.J z forthwith comply with such provisions or this perm if hall W deemed revoked.
Z CON MUC'D ON LENDING AGENCY
I hereby affirm that there I.a construction lending agency for the performance of
!Yi the work fur which this permit is issued(Sac.3097,Civ.C.)
III Q Undoes Name
L1. Under's Address
oz
U C) I certify that I have read this application and stem that the above information is
" fi correct.l agree to comply with all city and county ordinances and state laws relating to
0U building consuuction,and hereby amhorim representatives of this city to enter upon the
F yaWvomcntioned property for iospecuon per....
(We)agree m save,indemnify and keep harmless the City of Cupertino against
V) liabilities.judgment,costs and expenses which may in any way accme against said City
in cons
his
U of the granting of
APPLICANTcUNDERSTANDStANDrWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signawre mfA,pIicmVCcmWct.r Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wilby t applicant or future ni ipbuilding lode Chapter
r 9.12,,handle Health ad Safety al
az defined by the Cupeninn Municipal Cude,Chapter 9.12,and the Health end Safety
^..Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.Ye, ONo
Will the applicant or future building occupant use equipment or do.iecs which If a roof is installed without first obtaining an inspection, I agree to remove
it hazardous air contaminants m defned by the Bay Area Air Quality Management all new materials for inspection. - -
District?
❑Yes CI No
I have mad the haardous materials requirements under Chapmr6.95 crew Califon
ria Feclth&Safety Code,Returns 25505,25533 and 25534.1 undersmndds,ifthe Wilding
dens not cmamll,have a amsm,mat it is my mspo oihility to mufy the aeup.,nr the
regaBements which must W met prior to issuance or a certificate or Ownpency. Signature of Applicant Date
Owner or authorized agent Dasc All roof coverings to be Class "B" or better