03120077 CITY OF CUPERTINO ' *"'�
BUILDING DIVISION PERMIT XCO,NTkk&0 ANF0RMM ATION
BUILDING ADDRESS: MARK DEL CONTE CONSTRUCTZO PERMITN`63120077
F.M g�ltRVER DR PERMIT MUEDATE
CID 11 2 12004
SANITARY CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION
:gaj I hereby affirm that am licensed under provision of Chapter 9(commencing Job Description
<as with Section 7")of Division 3 ofthe Busircss Profoeou Code,and my license is
n�H in full forte doff Tim. S7//U
n�z cert chop Lic. 3 ADD 224 SQ. FT. & GARAGE 488 T .
DaM IuMcta�pd,my� y�s1y1FM S10cd
ds
3a� Licensed Pmfcssion�iall JUL O 'C4
Joon
S OWNER-BUILDER DECLARATION
iI I kmby affirm that 1 am exempt from dm Conmctor's License Law for theO O rollnwing Munn.(SectionIM1.5.Business and Nafestiorts Cade:Any city or county
g V which requires a permit to or.,.alter.improv,demolish,nr repair any structure Ruuvpm
prior m its issuance,also requires the apidieant for¢uch permit 1.file a signed smememt
that he is licensedimenumm thepmvisimm.ftk Comncmr's License Low(Chopmf9 Sq.Ft. Floor Area
1-$ Mommensingwith Section 7")of Division 3 oftk Businasand Professions Code)ur
that he u exempt Therefrom and tk basis fm the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of 3 7 .3'�l$t1 heV 0 Occupancy Type
not mom Nan fisc hundred dollen($SW).
❑1,as owner ofthe property,or my employees with wages OF their sok compensation,
will do the work and theawctum is not intended or offered for We(Sec.7041,Busirmse
and Pmfessm.Code:The Comvacm/s LittMe Low does Intl apply to an owner or Required Inspections
property who builds a improves thereon,and who does such work himself ar through his
own employees,provided that such improwments are oat intended mattered for We.If,
however,Ne building or improvement is sold within one year of completion,the ownef-
builder will have the burden of proving that k did nm Wild or improve for purpose of
sale,).
❑1,as owner of the property,am exclusively contracting with licensed mmmcmrs to
concoct the project(Sec.7000,Business and Professions Code:)The Cortmemrs Li.
cans,Law does not apply to an owner of property who Wilds or improves theremn,and
who contracts for such projects with a conuacmr(s)licensed pursuant he the Contractors
License Law.
pIamexemptunder Sce .Bk PCserThismason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby Fill.under penalty of perjury one of the following declantiou:
17;
haw and will maintain a CceifrtaM of Couenuo self-insure for Worker's Comi en-
n,u provided for by Section 37W of the Labor Code,for the performance of the
k for which this permit is issued.
have and will maintain Workcri Compensation Insurance,u required by Section
of the labor Code,for Ne performance of the work for which this permit is issued.
WorkehC pronation Insumnee comer and Poli umW
-��" F,1 '11 PolicyNo. ereU ZOo'f CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thixseelum need not kcomplemd ifthe permit is foronc hundred dollars($100)
or loss)
1 canify Nat in Ne performance of the work for which this Permit is issued.I shall not
employ any person in any manner an u to become subject to the Workeri Compensation
Laws of Califamia.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Centfreate of Exemption,you should
Without subject m the Waker'a Cnmpcaatiun pmvisiou of the Iskr Cede,you Meru
.J Z forthwith comply with such pmvisiou m this permit shall k decreed revoked.
?O CONSTRUCTION LENDING AGENCY
[.. I hereby affirm that Vert is a construction lending agency for thc Performance of
a the work fur which this permit u issued(Sec.3097.Ci,C.) 1
P. Q Under's Name
a z Lender's Address
U O I certify Net I have read this application and sum Nat the aWw information is
U. F' correct.I agree m comply with all city and county ordinances and Siad laws relating to
O U Wilding construction,and hereby autborim mpraenmtives of this city m cncer upon the
Uabovemenuoned proPcrty,for impaction purposes.
(We)agree to saw,indemnify and keep harmiect Ne City of Cupertino against r}�
F'faq liabilities,judgments.costs and expense which may in any way accrue against said City (//O✓//
C.J z in his Permit.
APPLICeof the granting of t
ANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-P TNI Issued by: Da
50}rRCE Ry�ATs O_NS. —
i�J//!Z,f� /3 61"7 Re-roofs
atgn. erre of Applic Dow
NAZARDOUSMATERIAIS DISCLOSURE Type of Roof
Stili the applicant OF future Wilding occupant store or handle hmallous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health,and Safety
adlic.6c.ScYrsion 255320)? All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant o faunu Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants u defined by the Bay Area Air(Duality Management all new materials for inspection.
0Ycs No
[haw Mad the hvacdousmzwHals mquimmenu under Chaplcr6.95 of thc Califor-
niaHwWhSafctyCodc,SccUmrM505.25533 md25534.1 understood thicifthc Wilding
docs note tly haw a¢nenL the iter my M¢ 'hility In nntily the ac tof the
regci k uamcafaCertifies.ofOccupancy. S ignature ofApplicant Date
w d All roof coverings to be Class"B"or better
Owner or authodred agent I Date