03030130 (2) F'U�,,LCDINGADDRESS:
TY OF CUPERTINO . °`+"' " '"'''T`y'
cIBUILDING DIVISION PERMIT ICOnrReGTO.RINOtMA'C7QN
" NAJERA CARLOS ET AL PERMIT NO.
ER'S NAME: PEIIIISSig A
NE: SANITARY N OL NO.
AR:111 111NOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH-
op
al j p LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job DescriP4''Qj1 (�
with
Section 7")of Division Sof the Business and Professions Code,wd my It..1, r' ALE93
o% in full force and effect _ e®
SN?;' Llcenso Clasr Lle.g REPIPE ,on
C ']
Dem DEC
ARCHI7LCo DECLARATION APR O H 2003
1 understand my plans shall be used As public mends
Licensed prof atinnat BUILDING'
OWNER-BUILDER DECLARATION
1 hereby affirm Ch.,I am exempt from the Contractor's License Law for the
O O following meson.(Section 7031.5,Business and Professions Calc:Any city or county
$ which rehires a pe ct to couwct star.improw,demolish,or repair any sorocuun
y,+ prior At is issuance,also requlru lhcapplicanr forsuch Permit to rile a signed ttsmmenl
tb< that he is Icamed pursuant to the previsions of the Contractor's License Lew(ChftPmr 9 - Sq.Ft. Floor Area Yalmtion
$ (commencing with Section 7000)of Division 3 or the Business and Professions Code)or v' U
Net W U exempt therefrom and tins basis for the alleged exemption.My vlohtiom of
Section 7031.5 by any applicant for a permit subjects the applicant or,a civil penalty of
not mors than ave hundred dollars($500). 3J�MN9TI�Pf00 Occupancy Tl pe
❑I.u ownor of the Property,or my employe with wages as their i tle compensation.
will do the wark and the shectum is notintended m alfered fmwle(Sec.7061.Business 202 - UNDERWat11411Ed P4MI3iVG
And Pmf.Wma Cade:The Consomme,Licerae law does not apply to an owns of
pomerywho Wildwrlmproves damomand whodaii work Mmselfur through his 301 - ROUGH PLUMBING
own emphoyeu.provided that such Improvements are not intended ormaarcd(m Ads.If. SO2 — '.FINAL PLUMBING ENERGY
however,me building.r improvement mold within one year ofcompletion,the owner-
builder will hove dm human of proving mat he did not bund or Improve for purpose of 507 — FINAL PLUMBING
ssG,).
(]1,as owner of the property,am exclusively convecting wire licensed convanon m '
conswn the project(See.7064.Business and Professions Cede:)The Contracmr's U. ..
more law does not apply to an owner or propeny who Wilds or improv themon.and, ,
who connotes for such pmjeeta with aconurttor(O Orerued pursasnl to the Convaemes
License haw.
amemosp u et Sec. .B&PCforthimason .
CieD
/ WORKERS COMPENSATION DECLARATIO
1 hereby affum under penalty of perjury one of the roll ng tied
I have end will maintain a Ccmficamof Consent to self-Insure for Workees Compen- -
line.u provided for by Section 3700 of the Labor Code,for the Performance of the
work for which this permit Is issued. _
1 have and will main Wn Workers Compensation Insurance,As m4uimd by Section
3700of the labor Cade,for the performance of the work for which this Permit issued.
My Workoes Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: .. -
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thls¢ctlhn need or be completed if the pormi3e forane hundred dnllars($100)
or less.) . .
1 certify that in meyyre+fnrmeace of the work for which this permit is issued,I shall not
employanyperautlganym gran m bjml la the Warkeri Compewlion
Laws of Cal if 1 g1t ctar u -
NOTICE PPLI NT:If,of c,making thi.CeNfmam of Exemption,you should
become su t to the orkees Compensation Provisions of the LtWr Code,you must '
�. foMwi comply with such powhiloas or this person shell W deemed revoked.
zO CONSTRUCTION LENDING AGENCY
F" I Wrchy sabre that there is a construction lending agency for the performance of
D: tis work for which this permit is issued(Sm.3097.Civ.C.)
ftl Q Lender's Name
z Lender's Address
U O 1 certify that I have mad this application and mm that the show Informallon is
{L F correct.I agree to comply with all city and county ominsnces and sea laws mhting to —
0U building construction,and hereby euthorim mprucnhaiv of this city to enter upon the
W above-mcmioned property for inspection purposes.
gy (We)agree to can,indemnify and keep harmless the City or Cupertino against
fA
liabilities.judgments.costs And expenses which may In any way same agamn said City
t.)7a in consegmnce of the granting of this permit.
a
APPLICAttr UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
sO^URFE E I S. �f��
" _ Seat Re-roofs
Signature of ApPlicaar
,A AR000S MATERIALS DISCLOSURE am Type of Roof
Will Use applicant or future building=open[store rehandle haurdoas material
As defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.seethe zss3z(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes76
Willthe applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
It ha'rardoos air contaminants as fined by the Bay Area Air Quality Management all new materials for inspection.
ostrich
❑Yea D
I have mad the hazardous mamrialsoupimments under ChaPmr6.95 orthe color. ,
ilia HWU&Safety Cedc,Sections 253115.25533 srd25534.1 understand Chat if tin Wilding -
dura nal cumcntl haw a tenwl,mat It It my msponAMlily otll'y 1W aceupant of c '
requhromenaw ch mum epdonoLuuanm on Ceninwm\ cu Signature of Applicant Dale
Owner tar wrhorired agent Date All roof coverings to be Class nBu or better '
' OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child) will perform:
• A. All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do: D O M
UD
A. _. All of the work !
B. _ A portion of the work (complete s f1iv;41003
Contractor Address/City Phone # ype of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property Owner's Signa`\t /e: 2T�e)
Job Addre3 8 L Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.