05010125 CITY OF CUPERTINOrro rru"R, rSaY
BUILDING DIVISION PERMIT Wo , TRACTnR INFORMATIQN
BUILDINGADDRESS: VITO REYES PERMIT N`05010125
071P NATRANq()N AV
W NER'S NAME: PERMIT ISSUE DATE
VITO REYES 01/21/2005
r r[ONE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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thatEDCONnsed m previsions
£ZasF 1 hereby affirm the I am Bahxd under provisions onC ride, 9(commencingsis Job Description
w with
lforce7frab ndifefDivision]of NCBusincst and Profcuiom Code,end my license is
Licene Cls and erR" REMOVE NON-BEARING WALL/50 % MIN.
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License Clan Lk.g
'h M Dam Conn.,., FINN
fWU I understand my pins shall be used aspbAR2cOds C f[Ca E
°oma Licensed Pmressinnal CN 9Ir-.YQ
,g OWNER-BUILDER DECLARATION rSQo�
<f 1 hereby affirm that I am exempt from the Contractor's License Law for the FEB L2005
O o following reason.(Section MIS.Business and Professions Code:Any city or county
5th which relumea a permit to enmtruct,mime,improve,demolish,or repair anystructure 2 0 0
-iy prior to its issuance,also requires the applicant for such permit m file a signed statement -
that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft. Floor Area Valuation
i $ (commencing with Section]000)of Division 3 of the B usinrat and Professions Cole)or
— Nat be is exempt theefrom and the basis for the alleged cxempdoo Any violation of
Section 1031.5 by any applicant for m permit subjects the applicant o a civil penalty of 3 Wker00 Oecu Type
not mom ren five hundred dollars(S500). p ane y yp
0 I,as owner.(,he progeny,or my employers with wages as dmu mle compensatinn,
will d9 the work,and the structure is not intended or offered for sale(Sec.1D44,Business
rad Professions Cox:The Consommes Liana Law does.1 apply m.a owner of Required Inspections
property who builds or impmvcs thereon,and who dosssuch work himatifor through his
awn emplpyou,provided Nat such improvements arc not intended oroRered forsale.If,
however,the building or improvement is sold within one year of Completion,no owner-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
0 1,as owaS of the property,am exclusively contracting with licensed Coronation to
construct the project(See.111!4,Business and Professions Code:)no Contractors U.
case lar data not apply man owner of pe y who Wilds n Improves themmn,and
bo acts for such proje of wits me moo s)Eanme pursuanno the Comfacmfs
L' Law.
l am ca Sc ,Bh P C forariaecYou
caner Dem V 2 //elf
WORKER'S CENSATION DECLARATION
I hereby alfinn under penalty f perjury one of the following decimations:
0 1 ban and will maintain•Cenifinm of Cement to self-insum for WorkefsCompcn-
sation,as provided for by Section 3100 of the labor Code,for the peefmmmue of the
work for which this Norm is issued.
0 1 have and will maintain Worker's Compemnion Inmrna,as delimed by Section
3100 of Ne Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compemahrut Insurance carrier and Policy number am:
Coria: Pal icy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuction need not he completed if the permit is intent,hundred dollars($100)
or lass.)
1 ccniN the;n` an the w a which this permit is issued.l shell not
employ any�srt� ym bee orsubjaua NC Workeei Compemation
Laws of Cahf
Applicant
NOTICE TO APPLICANT:B of taking this Cenifieam of Exemption,'a.should
become
subject m the Worker's a asation pmvisiom of tM IaMm Cnx.you must
�z fonow;theomplywithsueh'to onsonh;spera;d ,-,,dec dRd.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm mat there is•construction lending agency for the Performance of
x > the work for which this permit is issued(See.31091,Co.C.)
'is Q Lender's Name
Lender's Addrus
Z)z
J 0 1 today Nat 1 have read this application and Stam that the above information it;
y F collect.I agree to comply with all city and county ordinances and state laws relating to
oU building eonsmetion,and hereby amhoriae representatives of this city to enter upon the
Cahovome judgm property for inspection which may
(We)agree m mase,indemnify and keep harmless the City of Cupertino against
Jzin C.Ciestuancmentx costsandof this emit. reel in anyway accme against said City
in eonxyuewe of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of ApplicanUComnaor Dem Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applimnt or future building occupant store or handle ha mdous material
az defined by the Cupertino M 1 11 Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(ap All roofs shall be inspected prior to any roofing material being installed.
❑Yrs No
Will the applicant or furor Id;ng Occupant rex equipment If a roof is installed without first obtaining an inspection,I agree to remove
emit ha'rardous air conmminan az defined h thBa Area prmcm or demist which g P
Districts y Y Quality Management all new materials for inspection.
❑Yes ON.
[have mad the methhousmaterialare im o underChapmr6,95aftheCalifor-
nimHealth It ,Secdom255o5, and 34.1undersmndthvifde Wilding
does na aa a me my rea
s dolity to nouly the cupnt of the
re mems metPrio tris: cor.cmtifimmofoccupancy. igna[ureofApplicant Date
�/ Owner orauthoriudagent „e All roof coverings to be Class "B"or better