04030023 (3)v
CITY OF CUPERTINO
°'3 "'r r ` xaC `�"
�—
BUILDING DIVISION PERMIT
CONTRACTOR IN'�17'CtMATIO
BUILDING ADDRESS:
PERMIT N0.04030023
ER'S NAME:
PERMIT ISSUE DATE
SANITARY O. ONTROL NO.
HITECT/ENGINEER:
BUILDING PERMITINFO
I
PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONJob
Descri
I hereby arftm Nat 1 am licenced under Provisions or Chapter 9 (commencing
tion
Pandmylicenseis
tome and effect. Qt- 3
REPLACE SOLARIUM ROOF W/ RAFTERS--SKYLILGHTS
mDam a[+4 u A004
CONTRACTOR: RICARDO REMODEL
I ARCHITECT'S DECLARATION
I uroMmUnd any Plana Mall be used u public rcemrda
Licensed Pndessional
OWNER-BUILDER DECLARATION
License for the
I hereby alum that 11. exempt Item the Cssion,
o City O county
following mason (Section ](131.5, Business and Pru@ssium Code: Any city
which rtquis • permit to ems a)tar. improve, ri rtrNg s
Rmmcnt
prior to)has hectum
u the forsu h Permit t ed
Liceso o rile a Lacdsummcm
of Nc Conuines alxcnsessio Cheprer9
iucensed o,tlsamquims theapplicantor the Contractor's
Sq. Ft. Floor Area
Valuat 08000
(commencing with Suan70K)om Division Professions Cartelor
$ (commcncingwith SeNon T0nd of
.� Indiaofrnftxeged exemption.
that x 0 eumpt therefrom and the buil far IIIc alleged memption. Any vlalauan of
Section 7031.5 by my applicant for a permit Subjects the applicant to a civil Penalty of
APN Number
Occupancy e
ret mom than five hundred dollars (M3
P Y�YP
❑I, as owner of the property, m my employes with wage as their sale compensation,
32618043.00
will do the wah, and Ne Un cture is not Worried aoffered for We (Sec. 7014, Business
Required Inspections
and Professions Cade: The Counselors came sew does not apply lo an Owner of
property who buildsorimprovesthereo , and who doessuch work himulforthmu{h his
own employees, provided that such Improvements art not intended moffored tarsals. It,
��®
however. the building or improvement is Sold within one year ofeempledm. the Owner-
0�(r'—�}
Wilder will beve the burden of proving that x did on, build or improve for purpose of
sets.).
1, as Owner of the property. em exclusively communing with licensed contractors to
rs 2��4
SEp
mutoo m the project (See. TM, Business end Professions Cade:) The Contractors U.
come law does not apply to an ownm of property who Wilda or improves themm, and,
who contracts for Such projects with a conuncmr(s) licensed pursuant to the Contractor's
S q9
®�IIA,M
L" ore law,
�anpll
r�JJ Ib Y ro
1 em uempt under Sec. , B d P C for this moon
"
nor Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Koury one of the following declaruians:
I have and will maintain a CertiOmta of Comenuo self-imam for WarkersCompcn-
udon. u pmvidcd for by Section 37M of the labor Code, for the performanm of dm
work far which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Imtoanm, u required by Section
J]OO of the Labor Code, for Ne pertormantt of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF ID EMMON FROM WORKERS'
COMPENSATION INSURANCE
(ThOaectim, need nut momarpletod lithe permit is fortune hundred dalton ($10111
of leas,) ,-
1 certiry, that in the performance of the work for which thia permit o; issued. aha not
omployany per to so ua to s�ub�njec�t the Worken'CO
�msoner
etyo
IAws of California.- .¢-
�xcom�Ta I—
A tic ,-
N TO APPLICANT: IL after making this Certificate of Exempt n, fou Mould
sabjeet to the Worker's Compensation previsions of der V r Code, you most
>. forthwith comply with each provisions or this permiuhall x decree ked.
CONSTRUCTION LENDI 0 GENCY
,
Iherehy oRim last its consWctian nam{agcmyfo he perfunned. of
> the work for which this perm, Is issued (Sec. 3 , Civ. C.)
Louder'.. Name
> Lenders Address
ve rad this ion and a Nal Ne a Ww let ometim is
1 cenilA
correct 1 agrely with all rose o inancee and Bite laws relating lobuilding
Consd bomb u o osemativmof Nis city to enter upon the
4Date�
Wva-.moMy( Proposes.(We) p t if and keep harmless Uta City of Cupertino against
O Unbilitiu,judits hich mryin any wayamour.gainsl Wd City
> ineonsegmnein of is pesmu.APPLICANTAND
OMPLY WITH AL NO -POINT
Issued by:
SOURCEREN
S O
Re-roofs
Type of Roof
i nurao I nuContnct., Data
HAZARDOUS MA AIS DIS LOS U
the applicant Or forum Wlldi cursor to or handle herudous material
as dented by the Cupertino Munjcip dc. Clop 9.11, and the HcaIN and Safety
ode. Sc 3z(a)7
25s
All roofs shall be inspected to any roofing being installed.
YC'
❑ arm
prior material
Tr](/
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or f oocupam use equipment or devices which
it ha solom air contami U recd by the Bay Area Air Quality Management
all new materials for inspection.
Distriti?
❑ Ym
I have revel souden rtyuimmcnts undcrCMpte, 6.95 of the Caliroo
n,HzI"Safc undcmand Natifthe Wilding
does nor c ort tenant, that it is my respons t ray lo notify the omup of
Ed
aRxmetimortonswunceanCcmiRaalofoc
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner '.Omuimdagem
ta