02110049 (2) CITY OF CUPERTINO —
BUILDING DIVISION PERMIT CONTRACTOR'INF+ORMATION:
tSYu ,
EIIQLA,I774irlklisMEDINA LA PERMIT NO 2 110 04 9
OWN9RH&DEDER EDUARD AND MARGARET APPLICATIPIjSIIBSIdl'rf 2002
1
IONF.: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Op LICENSED CONTRACTOR'S DECLARATION Job Description
I herchy affirm that I am licensed under provisions of Chapter 9(commencing R I p
i with Scctinn]1kgQnl'Division3of NellnI�.espnd Prnfcssinm Cndc,andmylicensein
�< In full force a*ffecy, '7 / %— l
OZ Z License Chi�yylla Jk0 in, If �� /+• I
OW Date 4 /( 7, Crmr for //YY -_ -!
� a lundcs s�used Is cmd< L h
3�U J LLGZ o
11- Liccnud Pn cssional,
F �yJ 0 J OWNER,BUILDHR DECLARATION
a 1 fennyshort that I em exempt from the Contractor's License Law for the 5500
i 6 Q O following mason.(Section 7031.5,Business sold Professions Code:Any city or county
x g ff which requires a,permit to cowwct,alter.improve,demolish,or repair any someone
m�'^ prior in its issuance,also requires thcapplicam forsuch permiuo file a signed statement
That hp
e is licensed pursuant to doe revisions of Nnn
Ne Coors License Law(Chapter 9 2L10M(l Valuation
�th (commencing with Section 7")of Division of the Business and Professions Cude)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 1UJkPNN9WFR WATE.-,L Occupancy Type
not mmethan five hundred dmlara(ism). 202 - UNDERFLOOR P UMBING
❑ La sownerof the proseny,structure is employees withwageswtheirvole cW.Business
will Bothe work,Cod the Cool unit intended o Lawdoforole(Sec.]014,Bwinm
and Rvfeoiona Code:The Conloctory License Law dues not apply m an owner of 3 O 2 — TUB & Q�NCtIOnS
progeny who builds or improves thereon,and who doessuch work himself or mmugh his
own employees,provided that such improvements are not intended or offered forole.If. 502 — FINAL PLUMBING ENERGY
however,the building or improvement is sold within one year nfcompletion,the owner- SO6 — GAS TEST
builder will have the burden of proving not he did not(wild or improve for purpose of
ole.). 507 — FINAL PLUMBING
❑1.as owner of the propcny,am exclusively convecting wish licensed institutions to
construct the project(Sec.)044,Business and Professions Code:)The Contractors Li
cense law does nm apply m en owner or pr ry who NiIds lir improves themon,and
who nuacts for such projec isha m (s)licenudturownt to she Contractor's
is Law.
ec Imlde� .B&PC Ponhiueason
O er�
WORKER'S COMPENSATION DEC ON
1
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Cenificate of Common self insure for Workers Compere
sation,a provided for by Section 3700 of the labor Code,for the performance of IN
work for which this permit is issued.
I have and will maintain Worker's Compnwtion Inemwme,a required by Section
37M of the ISNr Code,for the performance of the work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number ate:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notnecompleted if IK Permit is fusion hundred dmlarn(SIIB
or lass.) nnn
I certify Out in the perfgLrngaoe of the work for which Nis permit is issued,I anal]not
employ any Person in an c r co suhjccuo the Workers Computation
Lawsof Califip9is.Dp � L
ApPI'ca ICO
NOTXO
0 APPLICANT:If,alter making this Cenilicam of Exemption,you should
hec Intent to the Worker's Compensation provisions of the ISNr Code,you must
OO foMwith comply with such provisions or this Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
[ti 3 Ihereby affirm that Were is a construction lending agency for the Performance of
ai the work for which this perm it is issued(Sec.3047,Civ.C.)
Q Lender's Name
Z Lender's Address
UO 1 unity that 1 hats read this application and sum that the allow information is
D+ F correct.I agree to comply with all city and county oNinames and sum laws relating to 69
0U building construction,and hereby millions,representatives of this city to enter upon the
na fdoon-ammioncd property for inspection Purposes.
(We)agree In save,indemnify and keep harmless the City of Cupertino against
y liabiltimsjudgments,costs and expenses which may in any way accmc against said City
U z ineenuprenuofthagso remingof is garrets.
o'^ APPLICANT UNDER AND n�D WILL COMPLY WITII ALL NON Issued by: Date
/!'dA %I ta Re-roofs
Wriattels of AppbconVCunvaclr uData
IIAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havallous material
as deOned by the C.Nnino Municipal Code,Chapter 9.12,and the Health slid Safety
,MNLCow. u All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant or future building occupant use equipment lir devices which
If a roof is installed without first obtaining an inspection, I agree to remove
•mit haaandous air conuminanu s defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑YesNn
Ihavereadthaan uhI usmamrialsmquimmenuundcrCNpwr6.95oftheCa]ifor-
niaHealth&safety Code.Sections 55115,25533and25534.1mor sundihstifthe building
does not urmn11 haw a un lit at it is my msp rnsihi ly as notify the occupant of she
reign Irw tugs to 5—:11camnf cup ry, /b ignature of Applicant Date
l I
er or authorized agent Dau All roof coverings to be Class "B"or better