02100202 (2) CITY OF CUPF,RTINO
BUILDING DIVISION PERMITCONTRACTOR INFQRMATION •t=:
Sr;s , ,
Bu111D2IQxS1RUSSANTA TERESA DR ABLE SEPTIC PERMITNO 2 10 0 2 0 2
OW1,%SjWEJACK Y AND GRACE N 520 REED ST. APPLICAI T16"Y"'Y 2 0 0 2
IONS: (408) 377-9990 SANITARY NO. CONTROL NO.
ARCHHECnENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Ido0 LICENSED CONrRACTOR;S DECLARATION gyp
a-PI hereby affirm that l am licensed under provisions of Chapter 9(oommeu01ng PROPERTY LINE le/Ve } OtACKFLOW
�<i with Section 7Oyq of Division 3 of the Business and Professions code,and my license is
F.om in full In.and effect.
zogz
License Class �-7Z LFo.x G77h 75
°L-° Dale CanuaclnrAr%S!C SYlsf/ G F91� ALE®
F=� ARCIIIT ECTS DECLARATION
y< I understand my plans shall he used as p.hire record..,
r°6DDEC 0 9 2002
- 0 Liccned Prnrcssinnal
FuOWNER-BUILDER DECLARATION
in
<E I hereby morin that 1 am cxcmpt from,he Contractors Liccmc Law far the $1800
1
w 00 following reason.(Smarr 7131.5,Business and Puelessions Code:Any city sur county �
$P which requires a permit to construct,alter.improve.demolish,Or repair any structureUILDING
td-'^ poor to illi ins ance,alvoreyuires aheappllcant forsuch permit it)file a signed summeel
�5�¢6 that he is licensed pursuant in the provisions of the Contractor's License US.(Chupter 9 3Tg6B16f0d12A&@ Valuation
F° monmenci ag with Section 7000)Of Division 3 of the East nes..,and Professions Code)ar
Nal he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of PNN Occupancy Type
not more than five hundreddollars(s5oo). 202 - UNDERFLOOR P UMBING
❑I,as owner of the property.or my cmpinyms with wages as their sole compensation, 3ei Reuel
will do the work,and the structure is of intended or offered for sale(See.70,11A.Businmis ��J,r
and Pmfessions Cade:The Contractor's License Law dors not apply to an owner of 507 — FINAL tlJ f"I �Cet10DS
property who builds or improve,thereon,and who does such work himsclfor through his
Own employees.provided that such improvements an,on intended or suffered for sale.If.
however.to building or improvement is sold within one year of completion.She owner-
builder will have the burden of proving Nat he did no,build or improve for purpose of
sale.).
❑h as mvrer of the progeny am exclusively contracting with licensed contrition 10
consumer the project(.See.RIS],Business and Profession Code)The Contractor's Li.
cense law does not apply to an owner of property who Guilds or improves Ihemon,and
who contracts for such projects with a com actors)licensed pursuant In the Contractor's
License Law. I
C]I am exempt under Sec. .B&P C for mis reason
Owner ,W r 91,16 Cy 7- Da¢ I o -3t,-eZ
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I haw and will maintain a Certificate of Consent m self-ineum for Workers Compcm
sxtion,as provided for by Section 3700 of the Labor Code,for the yerfofmance of the
work Iver which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3701 of the labor Code.for the performance of me work for which this permit is issued.
My Worker's Compensation horm nce carrier and Policy number am:
Cartier: 5r72TC `o..n d Policy lva, 1 7 _
CERTIFICATE OP EXEMPTION PROM WORKERS'
COMPENSArlON INSURANCE
(Ibis section need not IN completed if the permit is marine hundred dollars(I I0B
III lee.)
1 cent I that in the performance of the work for which this Permit IS issued,I shall nut
employ any person In any manner so as la become subjec uo the WorkersConfirmation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,of¢r making this Ceniticate of Exemption,you should
heetmic Subject o the Worker's Cone,nsation provisions of the Inbar Cade,you must
OO fourth comply won such previsionsor this perm'.(,hal I be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I-.V) Ihereby afftrn drat there is a construction lending agency for pcoromemeof
(k 7 the work for which this permit ixissucl(See 3097,Civ.C.)
W 0 Lender's Name
� Z Lender's Address
V 0 1 terrify that 1 have read this application and sur mat the aWw information is
F correct.I agree to comply with all city and county ordinances and state laws relating to
0 U bui lding eonxuuc,ion.and hereby authori m representatives of this ci ty to enter upon the
W above.mentioned properly l or inspection pure O,s.
(We)agree ba save,indemnify and keep harmless the City of Cupertino against
Nliabilities judgments.cols and expenses which may in any way aeric against said City
U in consequence of the granting of this permiL (/T1(J/
r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT Issued by: Date r6l
SOURCE REGULATIONS.
I !Z dB Gas
LRC-roofs
namrc of—A',plicanl/Gaaor Dae
I IABARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building acupunt,true or handle Avardnus material
ash, Lot by the CUPcrlina Municipal Coda Chapter 9.13,and the Stealth and Safety
etwe.Dyes zss3z(ar' All roofs shall be inspected prior to any roofing material being installed.
❑Yes `SJ No
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 haeallous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dimrut7
O Yes No
1 have mad She hannums materials requirements under Chapter 6.95 of the Califnr
Dia IlcalO&Snfmy Ctwe,Sections 255115.25533 and 15534.1 understand rho,if me bonding
I ties not currently have a tenant,mal it is my res onsibiltry m unity tbe occupant or the
rgairemntrwnitnmaatberecapAmmi.smanceofacemr-.I`rytupanty. Signature of Date
, w3 ,,7 H /0-3 ez
owaterOrmohmitedagent -� Date All roof coverings to be Class "B"or better