02100097 (2) i
CITY OF CUPERTINO
BUILDING DlvlstoN PERMITCONTRACTORiINFORMATION
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IluI2T+4414RFS6JINDY LA ACTION TEAM INC PERM]rN0.2100097
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GWP LIYEN: JIMMY D AND DEE Y 1278 ALMA CT APPLICAQP5,' 1_Ql`T�2002
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41 HONE: (408) 629-4433 SANITARY NO. CONTROL NO.
A R C I I I'FE.CTIE:NOI NITER: BUILDING PERMIT INFO
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LICENSED COMRACnOR'SDECLARATION
.e Ihereby afBrmthat
on3of On odunder
sandPisfonsafsCodc. 9(commencing REPLACE WATER tI A'I' e tion
�<� with Section]Ikall of Uivisiuns (the Business ane Pnsfessinns Calc.and myliccnscis
Foto in full force ffca� X SC V2.'
Zoe{? hicenu Clan cor
ozFp it T'SA'R
� ATION
gw� I understand my Plans trey d..,ppublic rxemds
HLLO Licensed Pmfcssinnal
OWNER-BUILDER DECLARATION
aZ u'�<I I hereby affirm that I am exempt from the Contractor's License Law for the $5600
S p O following reason.(Section 7031.5.Business and Professions Code:Any city or county
><$ which requires a Permit to construct,alter,improve,demolish,or repair any structure
m�'^ pdnr to its issoana,,also mummy the applicant torsuch Korattolile asignedstammcut
s'�x< that be is licensed purscard 1.the provisionsnf the Contractor's License Law(Chapter 9 3ffi162(7I0dC5AEb6 Valuation
FQ (commencing with Section TXXB of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and the basis for But alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit objects the applicant to a civil Penalty ofPNN Occupancy Type
not mom than five hundred doll..(s5o0). 506 - GAS TEST p y YP
D 1,as owner of the property,or my employees with wages as their ole compensation,
will do the work,and the structure is not intended or ffcad for sale(Sec,7W,Business
and Professions Code:The Contractors License Law does not apply to an owner of egmre nSpections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for ole.If,
hrweveq the building or improvement is old within one year of completion,the owner-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
ole.).
D 1,as owner of the property,am exclusively correcting �,tf with licensed contractors to 0 Ij A\
construct Ne project(Sec.714,1,Business and Prnlessinns Code:)The Contractor's Li. p
ceno law does not apply it)an owner of property who Wilds or improves thereon.and, OlI l 2OOL
who contracts for such projects with a cornmebo s)licensed pursuant m the Connector's
License Law.
D 1 am exempt under Sec. .B&P C for this reason
Owner Data BUILDING
WORKERAT
'S COMPENSION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of consent o self-insure for Worker sComPcn-
ofion,as provided for by Section 3710 of the labor Code,far the Performance of the
W
ork for which this permit is issued.
❑I haw and will maintain Worker's Compensation Inoonce,as acquired by Section
37N)of the Labor Cade.for On Performance of the work for which this permit is issued.
My Worker's Com notion Insurance caret and Policy num her am'
G ier7s,n 7RTI ` ah ; Q( �
CIiRTIIrICA Cor EXF. 10 WORK:RS'
COMPENSATION INSURANCE
(This section need not M completed If the permit is forms,hundred dollars($U10)
net less.)
1 cenify that in the get mo more of the work for which this Permit is issued.I shall not
employ any person in any manner so as to became subject o the Workers'Compensation
Laws of Cal ifomla.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ceniliexm of Eomptinn,you should
become subject to the Workers Compensation provisions of the LaWr Cndc,you most
OO forthwith comply with such provisions or this fend it shall he deemed revoked.
z N CONSTRUCTION LENDING AGENCY
(—, I hereby aubin Nat there is a comnuction lending agency for the performance of
ai the work for which Nis perm it is issued(Sec.3(N7.Civ.C.)
fat Q lender's Name
k1. Lender's Address
oz
U O 1 cenify thtl 1 have read this application and state that the hove information is
{T. H comma,l agree to comply with all city and county oNicances and stare laws relating to
DU holding constominn,and hereby notorious representatives of this city to enter upon Ne
ahovetms,judg dpnsperty for inspersion which may
W (Wid agree to save,indemnify and keep harmless the City of Cupeninn again¢
Vy in cou.sinq emwof he grats ntindof this permit. may in any way aceta,against said City
A APPLICANT
of UNDERSTANDS
this perm
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date w
SOURCE REG A'1'IONS.
c `Re-roofs
ignaturc of APPlicaFl✓AZuAn mUS MATF:RIAfS DISCLOSURE Uam Type of Roof
Will the applicant ar fLwmb ding rocupant pore rehandlehvallous material
as defined by the Caper no Muni al Cndc.Chapter 9.12,and the Health and Safety
Code,Section Y.25532(a)'t All root's shall be inspected prior to an roofing material being Installed.
❑Yea Na P p Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit haardous air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection.
District? /
DYes [I/
I have read the uoisolousmau rials requirements under Chapter 6.95 of the Califon
niu l Ralth&Safety Cando,Sections 25505,25533 and 25534.I understand that if lM building
res not ewrenlly have o mount,that itis my vespers hilit ufy the nccupor of the
myvirements whish must he mel prion¢issuance nfeCenifcan rl capn,x ,Signature of Applicant Dale
Owner or amhomcd ag Date All roof coverings to be Class "B"or better