03120030 (4) J
TY OF CUPERTINO3#a yy7�a �rBUILDING DIVISION PERMIT 1 CONT �. �d 41� � IA Y�L\aDING ADDRESS: PERMIT NO.03120030
ER'S NAME: PERMIT ISSUB DATE
IKIC SANITARY19 IiMOL NO.
12
NE:
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S DECLARATION
1 Imrcby affirm that 1 we liwascd under provisions of Chapter 9(commencing Job Description
with Suction 7").fDiviaian Sof the B.,mevand Profcasiuns C.&,.hd my license is p
mfell rorceondeffect.
LicDECK REPLACEMENT
Dam se Class Contractor
ARCHITECTS OECLARATIO �S( RETAINING WALLS JUN 9 2004
u rsun lana ell as public roc
n0
3o teas dPr a1•
OWNER-BUILDER DECLARATION BUILDING I hereby affirm that I am exempt from the Conwcsor's License Law for the v
S:o o following reason.(Swtion 7(D 1.5,Business and Profeadam Code:Any city.,county
Ing! which requires a pohnit to cnmlmcl,alar,improve.demolish,lir repair any structure
F�fy^ prior m its iuuumce.alsu requires theapplicant finetch penin 1.rile,signed statement
< that he la licensed punuenl to the provisions of to Contractor's License Law(chapter 9 Sq.Ft.Floor Area Va�j"000
go $ (commencing with Section 7000)M Division 3 of the Business and Profession Code7ur e'er
.. that he is exempt thcrofmm and We basis for the alleged emmption.Any vlolatlon of
Section 7031.5 by any applicam for a permit subjects the applicant to•civil penalty of APN Number Occupancy Type
not mom then Ove hundred dollars(SNA).
01,a owner o(We property,ormy employees with wages as Weir sole compensation, 34217063 . 00
will do thcworkand Westudum la ectumulad oro@rad forssm(S.c.70e4,Busineas Required Inspections
and Profession,Code:The Contractor's License Law dams not apply W an owner of q P
property who bu ild,or im proves Women.and who does such work himself or through his
awn employees,provided that such improvements am natimended or offered mrsau,if.
however,the building or improvement is sold within oro year of completion.We owner-
builder will have the home.of pm,mg to,be did oat build or improve for pu pore of '
ale.).
1,ea owner of We property,am exclusively connecting with licensed contractors to
construct We proje.(Sec.7044,Business and Promesiom Cade:)The Contractor's Li.
cense law dors not apply m an owner of property who Wilds m improve Wetoon,and
who cannca fat ouch project with a corms ctor(s)imenwi pursuant to We Cono m es
License Law. _
❑I em exempt undo gee. .B&P C far Nmas
is on
r Dau
WORKER'S COMPENSATION DECLARATION
1 bemby affirm under penalty of perjury one of the following decluratioas:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen.
gotten,as provided for by Section 37th of the labor Code,for We Performance of the
work for which Wis permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for tW performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Polity number see:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thosection wed nothecompleted if the permit is forone hundred dollars($1001
lir]Co..)
1 certify that in We performance.f the work for which this permit is issued.I shell nut
eel
an o in any manwrm as m bwome subject to the WorkcrYCompensation
laf f a.Dau
A
NTO APPLICANT:If,after making this Certcreate of Exemption.you should
subject to the Worker's Compensation provisions of the VWr Code you must
Zfthc�mply Z OCONSTRUCTION LENDING AGENCY
I bereby aRrm that Werc is a construction lending agency fan We perfonwnce of
> Wk fur which this permit Is issued(San.3091,Civ.C.)
L 's Nam.zL 'sAdd.1 comfy that I have mad Ws application and sato that We above information is
cI ag=he comply with ell city and county on inances and sum laws totaling Wbconsnetiun,and hereby authoring rcpmxnmives of this city to enter upon the
ahentione0 property for impeetian purposes(We)since to save,indemnify and keep hummu the City of Cupemno against
liec,judgments.cmu and expenses which may in any way accrue againsuaid City )inque...f the granting of this permit s/ >
APPLICANT UNDE_45_TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR R U 0
5_O
Re-roofs
rc ppl can HAZARDODS MATERIALS DISK URE Dam Type of Roof
Will the applicant or factum Wilding woupentshere orhandle ha oudoes memo&]
dcfned by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
e.Screen zss3z(an - All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Na
Will the applicant lir future building Occupant tin equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ha'rardous air contaminants as defined by We Bay Arca Air Quality Management all new materials for inspection.
Distie"
C]Yes ❑No
I hue mW the huramous materials requirements mukrChapmr 6.95 of the Califon
nix Health&Safety Code,Sections;35505,35533 and 25534.I undersand than if dm building _
Jars not currently hove a anent Wat LL is my rcspensitu m noufy tic occupant of dm
regaircmems which mustW met prior he in...or.Ccrd cam occupancy. , Signature of Applicant Date
owwr auth.rirtod agent Dane All roof coverings to be Class "B" or better