03100131 (2) CITY OF CUPER'I'INO
nun.Dwc mvlsloN PERMIT ONTRACTORF,O MATION
BUILDING ADDRESS: CCK CONSTRUCTION INC PERMIT NO03100131
.R'S NAME: FERMITISSUEDATE
]ONE: SANITARY NO. n CONTROL NO.
Z01 TiliciA RD
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O o LICENSED CONIEACTOR'S DECLARATION Ib Description
di F 1 hereby& at I am licensed OSCTIP
tl under provisions of Chapter Y(commencing
a� firm that
with Section7")af Division 3 of the Business and Professions Coda,and my license is
in rml force and effect. DEMO SHED License Class Lic.«
t Dam Contractor
e ARCHITECT'S DECLARATION
y pq 1 understand my plans shall be used as public mcorm
Dyes
g Licensed Processional - -
y3 OWNER-BUILDER DECLARATION
i<f 1 hereby affirm that I am exempt from the Contractor's License Law for the '
00 following reason.(Sondon 703 1.5,Business and Professions Cade:Any city or county
k$l which requires a permit to construct,alter,improve,dein utii i,Or repair any Mountain
i1 prior to its issuance.also mi the applicant for such permit to file a signed sutcment
-g3e that he is licensed pursuant the provisions of the Contractor's License Law 9 Sq. FL Floor Area ValUatlOn
tt -
Y S (commencing with Section 7011(1)of Division 3 of the Ilminessand Profusions Code)or
y that he is exempt therefrom and the basis far the allcgcd ascription.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to s civil penalty of 3 grpp Occupancy Type
.at more than firs hundred dollen(M).
❑I,as owner of the property,or my eroplayess with wage as their sale compensation,
will do the wart,and W."emc is not intended eoffered far-m(Sec.]044,But. Required Inspections
and[imitations Code:The Contracloes License Law does not apply m e an owner of q P
property who builds or improves thereon,and who does amh work himself ar through his
own employees.provided that such improvements are not intended to offered for We.If.
however,the building or improvement is sold within one yeti of completion,the owwr-
builder will have the burden of proving that he did not Wild at narrow for purpose of )
gain.). 5✓ 1
��//L as owner of tM property,am exclusively commeting with licensed convectors to
cc La the es a a(Sec,o an was of and Professions Code:)TheC_Ihacm.U. g f V
who c Taw does sol apply e ts owner of pmperty,who sed ro m imp thmarac aiid
who Law.for such projects withecontrumr(s)liunsetl purswm the Conwpaiy`,f'
Liunse each
I un cacmp under Sec .B&Pr 1 fir , n � �
Data ` !'
FTDRKE O ENSATION DECLAR l
i'
1'hercby anion under penally of perjury arc of the fo inn dei "
1 have and will maintain•Cenificam of Consent m-lbinsure for Warkei s Compon.
-tion.as provided for by Section 3]00 of the labor Coca.for the performance of the
work for which this permit is eased.
❑1 have and will maintain Worker's Compensation Insurance.-required by Section
3]00 of the labor Codc,for the perfamm"of the wart Rx which this permit u intend.
My Workefs Compensation Iasunnce carrier and Policy number art:
Ca Po1]ry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisscci anted notbecompleedifthc rermitisforenchundreddi($100) ,
of
I certify that in the perfmmance of the work for which this Permit u named.I shall not
employ any person in any manner an as in become subject to the Warker'Compeuation
Laws of California.Data _
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cotle,you main
.J O forthwith comply with such prePermit visions or this Peitshall W deemed mwrked.
'Z 0 CONSTRUCTION LENDING AGENCY
�T�1-i I hereby affirm that them is construction lending agency for the perrurmanec of
tYi > the work far which this permit is issued(Sec.IM,Civ,C.)
A Iendeis Name
] z Lender's Address
V Q 1 certify that 1 haw most this applications and sem that the above information is
IT. Fcame,.1 agree in comply with all city and county minorities and mm laws relating m
V building construction,and hereby authorise representatives of this city to toter upon Ne
W aboo-m
ventioned property fm impaction ptar s.
P., (We)agree to save,indemnify and keep harmless the City of Corns a against
rat Iiabllities,judgmenu,costs and expenses which may in any way accrue against-id City
fJ 7 In consequence of the granting or this permit.
w7 APPLICANT DERSTAND WILL COMPLY WITF L NQN-POINT Issued by: Date
SOURCE RE l 1/1
0(10 Re-roofs
nuts ofHAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
W the applicant or future Wilding occupant some or handle hsvallom material
as aeon by tic Cupertino Municipal Coda.Chapter 9.12.and tbe Health and Safety
f�D�� Sendan 25532(&)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or f lure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
J'rict?
haamdous airconuminsn6 u darned by the Bay ArcaAir Quality Management all new materials for inspection.
❑Yes kit
I have mad the hesndrusmsterials requm mcnB under Chipterd.95 of thin Califor.
nia Hu]tb&SafctyCode,Sections 25515.25533 and 25534.1 underwent ihuif Nin Wilding
dansnot cuncntly hew a tenant dmponanililym noury tic occupant n the
reyuiremen vancofaCcrtifuamo(OC cupanry., ,QsanatureofApplicant Date
Owner ora n- &gem D t�J� All roof coverings to be Class"B" or better