02110021 (2) CITY OF CUPERTINO ' '--- .
BUILDING DIVISION PERMIT CONTRACTOWINFORMATION:
BG11-1114a"'E"LINDY PLY TIMBERLINE BUILDERS INC PERMITN`02110021
OWNMV*L SCARLAT 22850 ASPEN DR. APPLICATITNT'?C?IFf2002
LONE: (650) 868-5291 SANITARY NO. / CONTROL NO.
- I
ARCHITECDENG INE ER: BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION ,]Q .�I$
eU I thereby affirmthat l am licensed underprovisions of Chapter9(commencing TEMP P WER $EICV lI-scription
ZZ It Section 7lNMy of Division 3ofthe Busi nJ ProfessionaCWe.orad mylicensc is
ZO= e.
nb m nmcand cffact. 6 gg�� iZG� EX y J Do Cl 1L/1,/z)` Cr rq ARCf11TECT'ST)IMLARATIONy �stmd my�Inns ah TIM sed as pts records ?
� P RE,
Bud Licensed Pnrtcasmnel
OWNER-BUILDER DECLARATION
MY I hereby affirm that I am exempt from the Contractor's License Law for the '
O following reason.(Second 7031.5,Business and Professions Code:Any city or county `
a which requires a permit to tom timet,alley,improve,demolish,or repair any swcture
prior o its issuance,also requires the applicant for such Permian rile a signedstatement
F�
that he is licensed pursuant o theArena ixod the Contrncurzs License Law(Chapter 9 Valuation
$ (commencing with SectionINC)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of N'N Occupancy Type
not m..than me hundred delta.($500). 304 — ROUGH ELECTRICAL
❑I,as owner oftle pmpedy,or my employees wish wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.70, Business Required Inspections
and Professi9ns Code:The Contractor's License Law does not apply to an owner of q p
Property
who builds or improves thereon,and whit does such work himself or through his
own employees,provided that such improvements are not intended or offered for aide.If.
however,the building or improvement is sold within one year of completion.he owner
builder will have the burden of proving that he did not Wild or improve for purpose of
.In.I.
❑1,as owner of the property,am exclusively contracting with licensed m nB6lors to
construct the project(Sec.701 1,Business and Professions Code:)The Conuaclor's Li-
cense law does not apply to an owner of propmdy who Wilds or improves thereon,and,
who comas for such projects with a contractor(s)licensed puru
mano the Contractor's
se Law.
am exempt u do,Sec. .B&P C far this rcuon _
wncr Oat L
WORKER'S COMPENSATION 0[CLA To 04
y
affirm under penalty of perjury one of the following declarations:
I
1 have and will maintain a Certificate of Cnnaent m edf-insure for Worker's Compen-
sation,as provided for by Section 371X1 of the labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of she labor Code,for the performance of tW work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPoON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if tW permit is forane Wndred dollars(511)())
or Icsa.)
1 codify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any in raoesm c h' t total Work
ees Compensation
L.Wa Of Celifam ia�� / ✓ L} { Z` f
A plicae_Tj�✓' ^7� 1
ICE TO APPLICANT:11;aper making this Ccnificaw of Excerainn,you should
memo subjmcl to the Worker's Compensation previsions of the Tabu Code,you must
O0 forthwith comply With we h provisions or this Farmitioull W deemed revoked,
Z M CONSTRUCTION LENDING AGENCY I
[� I hereby affirm that there is a construction lending agency for the performance of
�i the work for which this permit is issued(Sec.3197,Co,C.)
fiat Q Lender's Name
Z Corrects AJtlrcss
V 0 1 certify that I have read this application and suite that the above information is
Qr. cramming 1 agree to comply with all city and nmmy ordinances and stare laws r Upon t to
W4 above-mding entioned construction.and hereby authorize forinmction prposes.ntatima of Niscity mercerupon the
W above-mentioned age to erlyuse for an keep hs.
(s judgments,
agree to save,indemnify and kith hay in m IW City of Cupertino against
Uh Iiebmuctimus ofshecoatsmeponatiting ofhisPsmit. mayinanyway atttueegunxtsaidCity
V z in
UNDERSTANDS AND WILL C PLY WIT LL NON.POINT Issued by: Date ( "
SOUR�CE RS5•GUL�A)T)ON�S. �,,� J/ 5-/y
U l re3� ///f/st Re-roofs
at�rc o_f ApplfcaHAZARrulor o
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do,eCupemor future building re,Chapter 9.12.
handle Health and
u JcOtmd by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Code,Section 15531(.)? All roofs shall be inspected prior to any roofing material being installed.
p yes KN.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which I
•mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
Dyes 4N.
1 have mad the hazardous materials requirements under Chapter 6.95 of the Critics-
ria Health&Safety Cak,Sations25505,25531 and 15534.1 undersuitM Nm iftM building
does not currently have a mount,shat it is my responsid,dy
W on,IW nccupanl of the
require ratswhich usl frame prior it)issuance ce =-cupaney. Signature of Applicant Date
// ev All roof coverings to be Class"B" or better
wncr or authorized agent Done,