07090004 CITE'OF CUPERTINO
Ct� Tkt A CTQR I� ATI�Y
BUILDING DIVISION PERMIT
PERMIT NO.
BUILq{I�JQ pDglt,�,$$,LER AV RO SA TOE RES 07090004
�j Z$b jVj�J� PERMIT ISSUE DATE
OWNER'S NAME:
ROSA TORRES 886 MILItER AVE 09/04/2007
SANITARY NO. CONTROL NO.
INE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
ZLICENSED CONTRACTOR'S DECLARATION
w o 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is REMODEL BATHROOM SHOWER.
in full force and effect.
zLicense Class Lic•#
—O Date Contractor
.�
ARCHITECTS DECLARATION
i a< understand my plans shall be used as public rcc rds d b
�qV
W H icensed rofess nal
0 OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
no following reason.(Section 703 1.5,Business and Professions Code:Any city or county
$Li which requires a permit to construct,alter,improve.demolish,or repair any structure
z y prior to its issuance,also requires the applicant for such permit to file a signed statement �; Ft. Floor Area Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 .q
H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $7000
that 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 Number Occupancy Type
not more than five hundred dollars($500). 3 7 5 4 10 14 q(
I,as owner of the property,or my employees with wages as their sole compensation,
wilt do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or ttumugd his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,die owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's LiNkN ARY
-
cense Law does not apply to an owner of property who builds or improves thereon.and.
who contracts for such projects with a contractor(s)licensed pursuant to the Controctoes
License Law.
I am exempt tide Sec. B&P C for this reason
Owner f r7 Y�-4 Date a
WORKER'S COMPENSMYG ECLARATION
I hereby affirm under penalty of perjury one of the following declarations
0 1 have and will maintain a Certificate of Consent to self-insure for WorkcesCompen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws o(Califor�ta.Da��v'e ( y.
Applicant
NOTICE Ta APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you mus
Oforthwith comply with such provisions or this permit shall be deemed revoked.
j " CONSTRUCTION LENDING AGENCY
.�
�.t ►. I hereby affirm that there is a construction lending agency for the performance of
Q, > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q
Lender's Name
Z Lender's Address
U 0 I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorise representatives of this city to enter upon the
G a above-mentioned property for inspection purposes.
Q. (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: _
SOU CE ULATIONS.
✓ ® /OY 0 } Re-roofs
.gnature of Applican ontrac Date T O f R JOf
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hayardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs:;hall be inspected prior to any roofing material being installed.
❑Ycs
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 hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? r J
❑Ycs u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth Codc,Sections 25505,25533 and 25534.I understand thatif the building
docs noild'UrTentli have a tenant,that it is my responsibility notify the occupant of the
requircm Ls ich must be met prior to issuance of a Cc ftcate of Occupancy. Signature of Applicant Date
d All roof coverings to be Class"B"or better
tier or authorized agent Date