04010018 (3)CITY OF CUPERTINOT
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CONTRACTOR INO MA N
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BUILDING DIVISION ��„(vldy
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PERMITN004010018
BUILDING ADDRESS:
PERMIT L6UE DATE
R'S NAME:
SANITARY NO. CONTROL NO,
PHONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB M_EECCCHH
LICENSED CONTRACTOR'S DECLARATION
Job Descri IO
1 htreby affirm shit 1 am f the Bu wider andProf ns of s Cmda. o my license is
s withScctian70(Itp of Divixion]of the Business and Profcssionx Codc. and my license is
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in full forte and effect
DEMO (E) POOL FEB YOO4
Licenu Class Lk, a
.
p Give crm[,Kwl
3i ARCHITECTS DECLARATION
S dastard my plain shall W used az Public rtcnNx
BUILDINGLicensed
Professional
5 ' OWNER BUILDER DECLARATION
Law for the
1 hereby ,(See that I ore cxcmpl from Na CnnuanCo
m . county
e: Any city
ifollnwing ..on. (SccJun ]tIJ LS, Business dsioos Code: A
and ve. al,
which re4uire. a permit m cmnawcu, alar, impmw. Jemnlish, file
e. Sihny utu cn,
^ prior h) its issuance. also ,,quiresthe applicantforsuchPermilmBlcasigncJsiammcm
9
S FL Floor Area Valuation
q
Gthat he is licensed pursuan.to the pmvisions of NC Comlad.'s Licenu Uw(Chapter
(commencing with Section 7000) of Division 3 or the Business and Profession, Code)Or
$ Out he Ia exempt t, fl of
.. . muo
and 0. ban for to subjects the epxPmption. Any viPemioy of
for a an for
Oj all Nee Ileus m • civil rah of
VNr➢er0 0
3 q WMT➢
Occupancy Type
Senior by any pl set
not more than five hundred dollars ($500).
Drd
9V D'G
0 1, as owner of the p nptny, or my employees with wages as their sole eompen.mlon,
will do the work. and OR "co ,i, Out intended ornfferedl formic, (sec. 706E Business
Required Inspections
and Professions Cede: The Conuanor's License Law it= not appy to an owner of
pmpm, who builds or improves thereon, and who docs such work himself or through his
improvements ve out intended or offered for uta If.
.we employ.., provided that such
however. the building or improvement is ..to within one year a(completion, Ne owner-
,, will ban burden of peeving that he did not build or improve fun purpose of
buildve N
uIGJ.
owner of the propeny, em exclusively contracting with licensed nmuacmrs to
7044, Business pad Peefewmel Cade) The Contractor- Ll.
cmcuroa she project (See.
cense Law does not apply to an owner of prapeny who build& or improves Ihemon, and
who conuacta far such projects with a conuutor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am aempt under Sec. . B A P C for this mason
m Dale.. y '°
-
/v/ WOIFKEK320MPad�DN�rtt-AnATION
1 hereby affirm under penally of perjury o. of Ne following doi llosolons:
❑ I have and will maintainaCcrtifcole or Cnmem to self-insumforWohcr'aCompcn-
utinn, u provided for by Section 7700 of the labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Comp mmthm Insurance, rs reyvirtd by Section
3700 of Ne Labor cone, for the perfarman. of the woh (or which Nis permit i. issued.
My Worker. Compensation ]nmsance artier and Policy numher art:
Carrier. Policy No.:
CERTIFICATE OF EXEM P1104 FROM WORKERS'
COMPENSATION INSURANCE
mossestion need nolo. complcmd ll ibe Month is for one hundred dallan (SIM)
or to..)
I certify Nat in the performance of OR work for which this Permit B issued, 1 shall not
in so as a bcmme subject to OR Workori Compenmdon
-
employ any person any manner
Laws of Caliromia. Data
Applicant
NOTICE TO APPLICANT, if. after making this Cenificau of Exemption, you Should
Fame Subject to the Worker's ComPesssloo pmvisions of the Urn, Code, you most
,Z j fonhwO comply with Such provisions or this Permit hall be deemed revoked.
l
Q 11I CONSTRUCT]ON LENDING AGENCY
I hereby affirm Nn there is a coutrvcsion lending agency for Ne Tcrfonna en of
' "Ne.mrk for which this permit is issued (Sec, 3097, Ci, C.)
1 Gi Under's Name
Under', Address
z
) p I certify Net 1 have read this application and state that tc above information IS
concct. I agree m comply with It cis, and county mon... and,Ore laws elating to
Niscity tocnurupnn the
bullJingconswee
a W show mentioned property for Inspection pu,rIOYL
the City of Cugainst against
soand ve, indbyauthandmpres.mis, the
(we) agree to outs indemnify and kith
0.
s G may In an
� y liabilities, Judgmcnts.Costs and cxpcnaa which may In any way secret against mid City
)Z inC...,pen .1 0. granting of this Permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Date
Issued by:
SOURCE R r ULATIONS.
i -7-O
Re -roofs
'Type of Roof
sig a ofAppli.HAZARDO SURE
HAZARDOUS ERI ALS DISCLOSURE
Will he applicantser future building occupmtaum m handl. hmardous material
az de0ned by the Cupertino Municipal Code, Chapter 9.12, and she Health and Safety
All shall be inspected prior to any roofing material being installed.
191koder Section 25572(.)?/
pl Nu
roofs
❑Yts
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If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or fume building occupant vu tquipmetn or devices which
emit hamrdous ai, conurroolos u Orlo d by the Bay Area Air Quality Management
all new materials for inspection.
Disuict7
❑Yes �No
I have mad the haasNnus materials requirements under Chapter 6.95 of to Caliror
'
nia Hcalthdt Safcsy Code,S.dmu255n5.25533and25534,1un&c .dtui(tht Wilding
25533-
Docs not curmmly how a -Rantet it u my=m nosily the o.opmt of Nc
Date
re,ircmcros which must et Pionois uremia a Cernficam of Cup_
O
Signature Of Applicant
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All roof coverings to be Class "R" or better
Own o authorined a col Da¢
705 L/� A/ �
YI IAN 0 7 2004 N
1 t/411
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APPROVM
IN AAN�C
ITH E CITY 09
CUPEA ORDINANCESGATEj�ous� SIGNEDThis setSpecifications MUST
be kepta;l times and it is un n
lawful to make any changes or alterations 7
on same withcut w Stun permission from
the building Dept., City of Cupertino.
The stamping of this pian and specifications
SHALL NOT be held to permit or to be ar
: ';((tion of any provnsion�
env City Ordinanils nr Stv7SS,2 _
�3,