01100049 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10530 RAMPART AV MICHAEL MORGAN 01100049
OWNER'S NAME: APPLICATION SUB DATE
41 MICHAEL MORGAN 10/09/2001
PHONE: SANITARY NO. CONTROL NO.
C m Z ARCHITECT/ GINEER: BUILDING PERMIT INFO
P m O BLDG ELECT PLUMB MECH
A<i L_j U LJ L__.I
S h ELICENSED CONTRACTOR'S DECLARATION Job Description
Z= 1 hereby affirm Division
1 am licensed under provisions of Chapter 9(commencing /
:Ccc is in Sectionrom andefect. on3ofthe Business and Professions Code.and mylicenu EXTER. 6 OUTLET & SWITCH.
[m de< it in full farce and ellen.
m a Draw Class Lic.N
O!u nam Contractor
S BLL ARCHITECT'S DECLARATION
o,1 understand my pl...hall be used aco
s public rerds /
do O Licensed Professimml /
o! OWNER-BUILDER DECLARATION
M I hereby affirm that I am aempt from the Convacmr's License Law for the -
F-�_< following is ISec6om 1031.5.Business end Professions Code:Any city or county h 4 Q
Fr O
which requires a perms t can almq improve,demo]sh or repair any swnurt _ $
a3ec, poor tits ttalso reg _ theapplicant for such pmaroutto file a agnedmamment- — -- -
that M1 "1 d pursuant to the provisions of the Contractor s Lice Ise Law(Chapter 9
, s gggg . Valuation�1 73(commencing with Section 7")of Division S of the BuItimm,and Professions Code) .!t,
or that he is exempt northern and the basis for the alleged dirmulnu n.Any violation
of Section 1031.5 by any applicant para permit subjects the applicann
o a mil penalty
afron thanfvehundreddollars(a50o). 30ee pm !N fI ELECTRI AL Occupancy Type
.as ow ns of thropy.or memployers ployers with wages as their sole compensation, _
will do Ne work,and the structure is not intended or oRcud for sale(Sm.904,1.
Business and Profe.,ions Code:The Contractors License Law does not apply to an 505 - FINAL ELFg0ft(tM.VMctions
caner of pfopeny Who Milds or improves thereon,and who does such work himself
or drought his own employees.provided that such improvements are not intended or
offered for We.If,however,the Wilding or improvement is sold within one year of
completion,the owner-Milder will have the Wrden of proving Met he did not Wild cur
improve for Purpose of sale). '
M.
❑L as owner pro*p(Sm 7 4m cadrosBusiness
and[tomier.withCors,)sed Ths,Coments ra
_ License
the project(Sm 104,1,owner o and Professions Cade:)The improves
dimem. I
torra
License I co docs not apply men owner of a conty who Milds se improves thereon, f
and who cs License
(m such projects with a conwemr(s)licensed pursuant m the
Contractor's License Low.
❑lam diem to der Sec. B&PCfar this reason ^ •
OwnerX�
WORK ER'SC MPENSATION DECLARATION
I hereby affirm under penalty of perjury one or the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section 3100 of the Labor Code, for the
performance of the work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is
issued.MY Worker's CuTomm ion Insurance carter and Policy number ate:,
Catnci: ' e 'r� r Policy No.: f .rah. ,_.., '.... t l`. •�•i:h;
CERTIFICATION OF EXEMPTION FRQM WORKERS'] `= Y1 -v a .. s.t.!. 5 J
t -" COMPENSATION INSURANCE
' (This.amon.oced riot he completed if the permit is for one hmhdred dollars
ISIOIB or IessJ
I croupy that.in the performance of the work for which this permit is issued,I
shall not employ any person in any manner so as to become subject to the Workers
Compensation Uses of carfomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cd ificme of Exemption,you should
become subject o the Worker s Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall h deemed invoked.
r �8 "'CONSTRUCDON LENDING AGENCY
'1 hereby affirm that there is a consuuction lending agency for the pMormerm
DTII wbrkfor which this,permit is issued lice.3097.Civ.C.)
Q lender's Name'
Z Leder',Address; ,
V 0 I¢rtify that 1 have read this application°rad stem that the above mmonotion is
fsa F.r correct.1 agree to comply with all city and county ordinances and state laws relating
[� to Wilding construction.and hereby authoiim representatives of this city to enter upon
W the abovoincromned pmpeny for inspection purposes.
tom„ y. We)sum to save,indemnify and keep harmless the City of Cuperino against
tZ liabilities,judgments,costs sad expenses which may in any way accrue against said
V Z City in consequence of the graming of this permit. I.
PPLI ANT UNDERSTANDS AID WILL COMPLY WITHALE No P9Nr Issuedb Date
. '0 R�ER. ULA11Qy$._a /-r>_ ,f0,XX y
goo rcofApplicanVConracmr te 'I Re-roofs
HAZARDOUS MAfERIALS DISCLOSURE
Will the applicant m comm Wilding occupant mom or handle notorious mormial Type of Roof
as def Ned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety t . .
Codd.Section 255321.II. t s', . ; .l{"i`l :•; 1 s.., (•
'OYcs .... ,OND ' :'I., Q ..1. .. i I.: .
. All roofs shall,be.inspec[ed prior to,any.roofing material being installed.- .
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit homeruns air c"nmmiwnu ns definW by the Bay Area At,Quality Management
District? - all new materials for inspection. Applicant understands and will comply with
-Ores 0N all non-point source regulations: ..
1 have'read Ne hvardoas contend],requiiemems under Chittom 6.95 of the
California Health&Soms,Code.Sections 25505,25533 and 25534.1 understand that
lfrh,W ilding dms ret durmntly have.mnam.mat it is my responsibility m notify the
occupant fire requirements which ret W tact prior m issuance of a Croissant of
o"up°' r. Signature of Applicant Date
(G' 4 6 j All roof coverings to be Class "B"or better
Owom in trudwdrW.'rou
Data
OFFICE
i! .. r 1