04040011 (4) CITY OF CUPERTINOBUILDING DIVISION PERMIT .nC9►Nb6AQRINFORMATIQN i.
BUILDING DRAEGER CONSTRUCTION INC PERM'TNG.0404 —
HER'S NAME: - PERMITISSUEDATE
IRVINE APARTMENT M T MME 2004
ONE: SANITARY NO. CONTROL NO.
(408) 536-0420
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
adLICENSED CONnRACTORtitle, DECLARATION Job Desc yyyyssas,,,,pppp..,. uuuu rtrtmm
�u F I hereby affirm that I am fthe licensed i n ss pmvrtims of Chapter 9 my license is � �
zuci with Section]IXNB ofpivixion3 of the Business and Professions Code.and my license is I
e_`o rdn m full force and effect. STAIR REPAIR
Liow.Class Contractor of Dam Cun DECLARATION
ECL jI �t
l understand my plaussbell h used publ crecoords l I [004
OCT
I'a f, Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
'0 0 1 hereby.farm Bar 1 am exempt from the Contractor's License Law for the
❑O folwhich
re reason.(Section]ensu Business and ve,de i ori Codd:Any city or county
e m(Li which rcyuires a permit m construct.alter,improve,demolish,nr repair any structure
°Ic prior o its issuance,also requires the applicant for such permit to rile a signed statement 22
ESG that he is licensed pursuant o rile provoiensOfthe Contractor's License Law(Chapter 9 Sq.FL Floor Area Valuation -
xt- (cnmmcncing with Sordon]0(IB)of Division 3 of the Business and Pmfeesinns Code)in -
y Bar he is eaempl Ilmrefrom and Be basis for rhe allcgcd exemption.Any violation of ta �n�n
Section 7831.5 by any applicant for a permit subjects the applicant acivil penalty of 3 t1� al*aYlu�eT�O Occupancy Type
not more than fivd hundred amlars(95WL P Y yP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the a rucmre is not intended or offered formic(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thcrcon,and who does such work himaclfor Brough his
own employees,Provided that such improvements erenal imcnded or offered formic.If,
however.Be building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving Bat he did not build or improve for purpose of
sale.).
as owner of the propeny,am exclusively contracting with licensed contractors to
ons met the project(Sec.7844,Business and Professions Codc:)The Contractor's Li.
cense law does not apply to an owner or property who Wilds or improves Berton,and,
who contracts for such projects with a contractors)Ecensed pursuant o the Contractor' -
License*.inLai
❑lam B&PCfor this onnefDarMPENSATIONDECLARATIONlly of perjury one of the following declarations:
Ihmifcare of Consent m self-insure for Workers Compete
a iti m,as Provided for by Section 3708 of Be Lbor Code,for the performance of the
work for which Bis pctmir is issued.
1 have and will maintain Worker's Compensation Insurance,as requited by Section
37M of the labor Code,for Be performance of But work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the permit is for one hundred doles($Ig)
or lost.)
I certify thin I.the performance of the work for which this permit is issued,1 shall net
employ any person in any manner set as to become subject to the WorkersCompensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IE after making this Certificate of Exemption,you should
become subject m the Workers Cobble motion pmvisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall W deemed revoked.
'Z' CONSTRUCTION LENDING AGENCY
[-. I hereby affirm that Ihcre is a construction lending agency for perrermanw of
Be work for which this permit is issued(Sec.3097,Civ.C.)
RWi Q Len Ices Name /^\
Z Lender's
U Q 1 cenify
Bet 1 have read this application and stele ordinances
athend above ws rmuing is
gL F bonder,I agree to comply with all nth and county nmtives Of and Cram laws relating to
pU buitwturetimund construction,and hemhyemM1on prrtprcscmativcsuf BisCity mcnmrupon Bc
show-mentioned pmpc costs
(an inspection which ms.
r�y (We)agree Io save,indemnify and keep harmless the City of Cupertino againu
nF.r N liabilities,judgments,cosh antl expenses which may in any way scenic against mid City
in cNN
granting an Ibis permit.
APNDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOI
Re-roofs
Signature f pylic C n boor ale
IIA A GUS MATERIALS DISCLOSURE Type of Roof
Will Capp more building occupant store nr handle Innocuous mmcfial
as derined by the Cupeniao Municipal Code.Chapter 9.12,and the Health and Safety
x1dModc,Sc❑cliea 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Will Be applicant or mwmnbuuJing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,h hnzardnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
trier?
❑Yes
Ihave read the hurardous mainulstequiremenm under Chapter6.95 of the Califon - - -
nia HCom&Safey coda,Sccduns 255(15,25533 and 25534.1 undcrsmnd Belif Bc building
Joan ca*A!�nily rrcq suance of a Certificate of Occup c. Signature of Applicant Date
ow All roof coverings to be Class "B" or better.