06100137 CITY OF CUPERTINO
BUILDING DIVISION PERMITTIoN;
BUILDING ADDRESS: HOLDER INC DBA ABLE GLASS PERMIT NO. 06100137
1458 S STELLING RD
OWNER'S NAME: PERMrr ISSUE DATE
DAVID PUGH 1129 RICHARD AVE 10 /18 /200r,
)NE: SANITARY NO. CONTROL NO.
(408) .739-8829
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
V1 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
2 w with Section 7000)of Division 3 of the Business and Professions Codc,and my license is
=y in full force and cff REPLACE (7) WINDOW & (1) PATIO DOORS LIKE FOR
t o? License Class Lic.#
F
in Date Contractor LIKE
.J
� ARC CPS DECLARATION
W U I understand my plans shall be used as public records
,a
H Licensed Professional
t y.< OWNER-BUILDER DECLARATION
j e 1 hereby affirm that 1 am exempt from the Contractors License Law for the
:00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
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
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuati 9 0 0
t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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 Occupancy not more than five hundred dollars($5W). 36624001 . 00
APN Number ber p y T ype
C]I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through 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,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑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 Li-
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 Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
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 Workees ompensation Insurance carrier and Polity number are:
Cartier. <<4fd Policy No.; Ir
CERTIFICATE OF I PTION FAOM WOMIM W1
COMPENSATION INSURANCE
(This section need not be 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 Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z 0" CONSTRUCTION LENDING AGENCY
E~-r►�-, I hereby affirm that there is a construction lending agency for the performance of
p; the work for which this permit is issued(Sec.3097,Civ.C.)
Owr(0 Lendces Name
z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
w r r correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
,.q to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the 'ng of this permit.
�. APPLICANT UN NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 16Lt O�
SOURCE REGU 10'a'
Re-roofs
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
code.Section 25532(a)7
C]Yes No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buil ing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.nit hazardous air contaminants fined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health��a
ons 25505,25533 and 25534.1 understand that if Nc building
docs not ct that it is my rcsponsihility to notify the occupant of the
requiremeet prior to issuance of a Certificate of Occupan Signature of Applicant Date
�or���0,6 All roof coverings to be Class "B"or better
Owner or authorized agent Dam