03040058 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
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BUILDING ADDRESS: PERMIT N'03040058
Oh3040058
.R'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECTfBNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+00 LICENSEDCONTRACTOR'S
inic,SDECLARATION Job Description
I ionhereby70 afRrm Nei 1 am of do,
Be under and
limons of Chaptor 9(commencing - p
with Section]OIXgof DivisionJofthc Ousinors and Pmfcssiam Cadc,end my license is
+ „ in mumraandeffect.
DEMO OF (E) HOUSE
License Claim .as
Dale Contractor
Fq ARCHITECTS DECLARATION
2 I understand my plans shall M used as public records
6
e� Licensed Professional
OWNER-BUILDER DECLARATION
Cay I naso affirm that 1 em exempt from the Contractors License Law for the
00 followingreran.Permit
]cont, Business and ere.de rum Code:Any city or manly
5 which mquirus n pemio re cnnffiuc6 alter,improve,demmsh,or repair any structure
i- Our to ill issuance,also requirestohe the applicant for such permit m rile s signed stammer
mmhireenxdwnaanH0mepmdamonoftheBusinroraumnxLaw ssonChapmr9 Sq.FL Floor Area Valuation
�F,G (commencing,intxempt ffiemfon rom add 00)
Divislofr the
theBedexess mton.Any
Cuoc)or
that he u exempt therefrom and the basis far the alleged exemption.Any vieladon of 37508018 . 00
Section 7031.5 by any applicant for.permit a iii theapplicant m.civii pcnelly o
not mum man Rve hundred delta.(S500).
-.._ .. . - --f APN Number ._ .. Occupancy Type
❑1,ac owner of the property,or my employees with wages as their ionic compensation,
will do th,work.and theawmurt is nut Intended orof(ertd for eels(Sec.]064,Businms 704 - DEMO
and Pn,rwmns Cade:The Conuxmrt License Law does not apply to an owner of _ Required Inspections
propeny who builds or improves thereon.and who docs such work himself or through his
ownempleyces,provided thauoch improvemenmane notimmndedoroRered forsale.If. -
however,the building or improvement is wild within one year of completion,the owner
builder will nava the burden or proving ren he did not Wild or improve for purroac of
sal.j.
❑ 1,as owner of the property,am exclusively konmcting with licensed contractors to
construct the pmjeci(Sec.]Oda,Business and Professions Code:)The Cmaracteri Li-
ttre law docs not apply to an owner o'property who Wilds or improm dmmon,and
who contracts for such projects wit a conmactor(n)licensed pursuant o the Con ractora
License law. Ob
I&I an exempt under Sec. ,B&P for this reason
Dam
WORKER'S COMP ATION DECLARATPOZA
1 hereby arlon under penalty of perjury ou of the following declantiens: V�
I have and
will meinmin a Cenifcam of COnum m self-Insure for Worker s Compen- �Y
urian,u provided for by Section 37W of the labor Critic,for the pertarmancc of me
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Coale.fur Be performance of dm work for which this permit is Issued.
My WDrkees Compensation Insurance cant and Policy number art:
Cartier: Pal icy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This umion need not W completed if the permit is roronc hundred dollars n](0)
or Bits.)
I certify mat in the performance of the work for which this permit ot issued.I shall not
employ � ic
me Wmken'Compensadon
Laws ofiype n99�y �;q!!aL!—V w
P ties
ICE TO APPLICANT:If,after making this Certificate of Exemption,you al
came subject to the Worker's Compensation previsions of the Labor Code,you mon
Qforthwith comply with such provisions or this permit shall W deemed revoked.
ZoCONSTRUCTION LENDING AGENCY
I hem ry affirm mal them is a construction lending agency for the performance of
Yam the work for which thin permit is issud(Sec.3W7,Civ.C.)
y 0 Lender Name
3.3. Lead e,Add..
Q 1 certify that I bave reed this application and stem that the above offs mtiun Is
y Fconem I.,me to comply with all city and countyoohn ions and state laws rotating to
U building construction,and hereby authmim oprom ativm of Nis city to enter upon the
C .hove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City Of Cupertino agarum /'
N lobilidas.judgmenm.costs and expenses which may in anyway accrue against aid City //
in
J^
APPLICANTgeof the granting a(UNDERSTANDSAND Ihis rWILL COMPLY WITH ALL NON-POINT Issued by: Date
ivi,
ULA
9 Re-roofs
Applicanuc nor mor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the applicant or fuwre building occurrent store or handle harsrdoun material
y the Cupertino Municipal Codc.Chapter 9.13.and the Health and Safety
n 25533(.)7 All roofs shall be inspected Aorto an roofing material being installed.
- x I�Nt P P Y g g
the applicant or future building arupantux equipment or devices which If a roof is installed without first obtaining an inspection,I agree[o remove
us air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
r I?N.
I have mad the humNnus nu uniub myuimmenu took,Chapter 6.95 of me Califer.
nu Health&Solely Code,Sections 25505.25533 and 25530.1 understand thou if the Wilding
door not currently hue a Ienmt Net it is my respomihiloy to notify the occupant Of the
rets' hmhm mmpdnrt sstaneenfaCcmficamofOccupancy. Signature of Applicant Date
cr or amharimd agent p All roof coverings to be Class "B" or better -