03120100 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INF0RMATR
a t ck{M zA °
BUILDING ADDRESS: PERMITN0.03120100
OWNER'S NAME: PERMIT ISSUE DATE ,
GALRY RRANnRNRTTRP /I 7/90
!E: SANITARY N0. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
H O ZO LICENSED CONTRACTOR'S DECLARATION Job DOSCTI SI O
u F 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
n� with Sermon 7WB)or Division 3 of dm Business and Professions Code,and my license is
NNALED
D in full fame and effect.
License Class Lies ADD GARAGE 427 SQ. FT. /REMODEL
�t-O Dam TS ECr NOV Is' 2004
ARCHITECTS DECLARATION
pZ 1 understand my plans shall W used az public records
�WU
Licensed erchy affirm
BUILDING OWNER-BUILDER DECLARATION VK I\Y,(V�
.�0 2 I hreaso affirm thin 1 ore exempt from the Contractor's License Law for the
OO roll.which re rias,..Permit
170extr Business and Pmfderinns Code:Any airy or county
4.� which requires r permit re uirswce epee improve,demolish,or repair any strumurc
L=� prime.slicensedpurlso uantto thees,the vistimofcant thesuch pmmiuofile a nse signed statement
(com£Z< thatmehe ncing with
pursuant of Division 3 theeBusinessandlimclaons Code)or
Sq.F[. Floor Area Va osteon
'at he
is exemithhebtion71k10hu Division3 of ai Business and Professions Codc)or
y 3 Natio is exempt thcrcfroo and or basis for the alleged exemption,Any lineation of
reclio.me. by veanyappldollarorapmmissubjccutheapplicammacivilpenaltyof 37WNftM*grp0 Occupancy Type
not more Nen five hundred dollars(5500). P y yP
❑1,as owner of the property,or my employees with wages as their sale conepensstion,
will do the work,and the structure is not intended orofremd forsalc(Sec.7044,Business
and Professions Code:The Contractor's Lt...Law does not apply to an owner of Required Inspections
prapeny who builds orimprows thereon,and who dommah work himself orthrough his
own employees,provided Nm such impromemenb am not intended or offered forsalc.If,
however,the building or improvement is sold within one year or completion,the owner-
builder will have the burden of proving that he did not build or improve fur pumoac of
We.).
KsL as owner of the property,em exclusively convecting with licensed contractors to
wat the project(Sec.7D44,Business and Professions Code:)The Contractor's Li.
cense law docs not apply to an owner of property who Wild,or improve marine,and
who contracts for such pmjecu with a conmcmr(s)licensed pursuant be the Contractors
License taw.
❑tem($�Je�,mptmmorcec. ,B&PC for this rcazon
O ✓YK R'$COMPEN� $ATION DECLARATI(vJN
1 hereby aRrm under penally of perjury one of Nc fallowing declarations:
have and will maintain a Certificate of Consenl to selfdnaum for Worker's Compen.
sation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 ban and will maintain Workers Compensation Insurance,az required by Sectio
37W of the labor Code,for the performance of the work for which this permil is issued.
My Workers Compensation Insurance carrier and Policy number am: .
Cartier. Policy No.i _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is foronehundred dollars($100)
lass.)
I certify that in the perfin nesse of the work for which Nis Permit is issued.l shall nut
employ any Person in any manner sol as to become subject o be WorkersCompensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certifiew of Exemption,you should.
become subject to the Worker's Compensation immersions of the Labor Cnde,you must
.J O forthwith comply with such provisions or this Permit shall W deemed revoked.
z"� CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for performance of
Ri rte. the work for which this permit is issued(Sec.3097,Civ.C.)
A Lenders Name
z Under's Address
V Q 1 certify that 1 have read this application antl sae that the above infomatiun is
II. F correct 1 agree to comply with all city sold county ordinances and stale laws relating to
pbuilding construction,and hereby aulhormm mrocientmives of this city to enter upon the
Uabove-mentioned properly for inspection proposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against _j6
LF.t p)
liabilities,judgments,costs and expenses which may in any way same against said City //
r) Z in consequence of me granting of this permit. /
" APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGQ,1\,p�T\IOINS. '2�.'��
oofs
'BI�re�it HAZARDOUS MATERIALSnNomormair m - TypeRe-r of Roof
Will the applicant or Noto building occupant store or handle haaardous mammal
m denned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. .
Yes
Will the applicant or future building Occupant rte equipment,r devieea which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air comma mants as dcfmcd by the Bay Area Air Quality Management all new materials for inspection.
lrict1
❑Yes P.
I have read the hara boos materials requirements under Chapter 6.95 of the Cxlirm.
nix Health g,SafelyCodc.Sermons 25505,25533 and 25534.1 undersand that if the building
does no currently haw a tenant that it is my reeponsihilky to notify the oecuPent Mthe
moire owns• the melrior ;satyrs.ora Ccrdneam of Occulder Signature of Applicant
i Dale
^u9
P
,let m
et or lhmixed agr 1, _V1
All roof coverings to be Class"B" or better