03110001 (4) E.ER'S
CY OF CUPERTINO '
BUILDING DIVISION PERMIT t�CONTRACTOReINFORMATTION �',
DING ADDRESS: PERMIT NO245 MT CREST PL
NAME: PERMIT ISSUE DATE
GARY NEWMAN 11/03/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECfyENGINEER: BUILDING,PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op
LICENSED CONTRd todo,S DECLARATION Job Description
2 yF I ionIncoeb,70 affirm that I am of due
under nd Porfns of Chapter (commencing p
E withll Ire n]OlkBof Division 3ofthe Busincsa and Prokssiuns C.&..ad myliccnsa is
EE inraumrtedpsyerred L� � REPLACE WINDOWS
'y�"z_ License
CONTRACTOR: EXCELLENCE IN REMODELING
.F Dau Conwmnr
eHITECTS DC J
L 1 undcramnJ y plana shall W used a(mlllh records
U
GG Licensed Professional
3 OWNER-BUILDER DECLARATION
�<Y 1 hereby aIEma that I am exempt from the Contractor's License Law far in.
20 following mason.(Section 703 1.5,Business and Professions Code:Any city or county
m which requires a pe.mil b)construct.alter,improve,demolish,or repair any structure
prior'ar it,issuance.also requires lheapplieamforsuch permitto flcusigned statement
x< that he isliccnmdpursuanttotheprovisions(iftheContractor'sLiccdsclaw(Chapter9 Sq. Ft. Floor Area Valu
Z�C (commencing with Section 7")o1 Division 3 of the Business and Profcssionn Coda)or
$
that he is exempt Therefrom and But baso for lie alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject,the applicant to a civil pendvy of
nor more than five hundred dollars(S500). er' Occupancy Type
I,.owner of the progeny,or my employee with wages as thou sole compensation,
will do the work.and Ne auuaure is not intended or offered for sale(Sec.7054,Business
add Prefesaions Code:The Conuacmra License Law does oat apply m an .act of Required Inspections
property who builds provided imprnma Merton,andwho.. esti twok himselro.through his
ownemployees, inori p such impm old wit arenor ear dedof
completion,
far sold If,
however,the building or improvement is Bald within one yet,of completion,the owner,
builder will have Ne buNcn of proving that he did not Wild or improve for purpose of
sok.). �2/
❑L sa owner of ct rampart,70a am eulusiv and
Proloid.,with i The
contractors r'sm
came La Ne project apply
to in ownBuser
of and Pm who Wilds
Cad.:)The es Unereon, Li-
came law docs not apply m in owner of property who sed p or improves Merton,and,
whocommentLro for such project,with o eomricmr(q licensed pursuant to esu Cmm�norS
License se Law.
1 em exempt under Sec. .B h P C for this reason
er Data
WORKER'S COMPENSATION DECLARATION
Ihereby affirm under Penalty of perjury one of the following declarations: - -
1 ham and will maintain a Cenlficam of Conserv to self-inaum fur Worker's Comped.
ostia,as provided for by Section 37W of Ne labor Code,for to perfarmance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation li mrance,as required by Section
1700 id the labor Cade,for Ne performance of Or work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Ca.ricr. Policy No.: .
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE
flus section need at W completed if rhe permit is foram hundmddellara(S 00)
less)
1 certify 0.1 1.Or ratio. of he work Wr which Nis Pe.mi u roueqq.,I shill net
employ any person' ymanner mb floe bjceua Ne .ken' Txado,
ran of CaIitoiniA3lgfe
Applicant
NOTIWO APPLI ( cr g a nifgau of Excmptioa Ynu should
raccoon Eject to the Workers Compensation provisions of the labor Code,you most
Oforthwith comply with such provisions or this Permit shall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affrm Nat there it,construction lending agency for Nc Performance of
3i the work(a,which this permit u issued(Sec.309],Civ.C.)
y 0 Lender's Name
7 Z Lender's Addrtas
C 1 terrify that 1 have read this application and stave Out Be above information is
L I correct.I agree to comply with all city and county ordinances and sum laws relating to
�U building construction,and hereby authorm representatives of Nis city to enter upon the
, ahavo-me judg tl pmpc costs
for ex,cdon Purposes. �V
(We)agree to save,indemnify and keep harmless the City of Cupcnino against
to incoitics,ludcofthecomanger aPermit. may in my way ucme against said City
,z in comequencc o(Nc manger spermit.
^ APPLICA UND AND ND ILL COMPLY WITH ALL NOP01 Issued by: Date
SOURCE L T NS.
Re-roofs
upon co icanUCu or Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or
futu.e building occupant sore or handle hnutlous material
u OeBncd by On Cupertino uni opal Code.Chapter 9.11,and Ne Health and Safety
. 0
Section 255320)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
Will Lha ipphcanl or rerun bndd a, occupant gars equipment or devices which If a roof is installed without first obtaining an inspection,I agree to.remove
II Imtemous air conmminanu an defined by the Bay Arca Air Quality Management
District? all new materials for inspection.
Cl Yes )(No
1 hatsmadmeler+ociusmaurialsrtquimmcnuunder ,Chapter6.95of Ne Callror,
ria Hmhh&Sarcvycake um25 5.15,Sfl3ud Z5534.1undcuwtl Nwi(&Wilding
does not eio ch y ave u in,N t is y marine! i1itY m n ufy t eupanl of Ne
not samenu IE ,mer or'smnccofaccnlfrea or aPeney, Signature of Applicant Date
Owner err arize ugemr All roof coverings to be Class "B" or better