04010072 CITY OF CUPERTINO
BUILDING DIVISION PERl� CONTRACTOR,INPURMe�ON
BUILDING ADDRESS: IMWALLE ISTEGNEZ PERMIT No 04010072
91 r)[)n -,TENTENS CREEK RD 4 200
a NER'S NAME: PERMIT ISSUE DATE
TMWALLE TRTEGNEZ 21 000 STEVENS CRETEX RD ';/211114
NE: SANITARYNO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:00 LICENSED CONTRACTOR'S DECLARATION
�u+F❑ 1 Wrchy affirm that I am IicenuJ under provisions of CM1aprer 9(commencing Job Description
ZW with genion]Otlf)af Division Softhe Business and Prufessinna Code,endmylicenu is ,
<<.„ iLicenn mBrnmesndeffnut. J"D DEMIZING WALL/RESTROOM& (SPACE #2)
&a Z u C
ON (J�
1 undcrsunJ an us s bile conn
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;a< LicensedPntfessions APR 1 4 2004
i OW -B ER DECLARATION fT 1
<y 1 hereby affrm that 1 am xempt from the Contractors License
Law forum
'
O o following reason.(S ihhhi]IIB Busincu and Profession Codc:Any city or chanty
Eno
S� which maim.a permit m ca trust,alwc improve,demolish,he repair any strucmm
°yy POurtoits as.... is. O"heanf�r such"mum flee aigned smlemcnl
BUILDINQ
pZ< that he is licensed pursuant in the provisions of NC Contractor's Licenu Law(Chapter 9 Sq.Ft.Floor Area Valuation .
yH� (commencing with Section 70)(0)of Division Sof the Business and Professions Cade)or
that he is exempt therefrom and the buss for dm alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of th3 �.Motgro 0 Oeeu anC G
not main an five hundred dollars(S5W). P Y PrP
❑I,as owner of the proforty,or my employees with wager as their sate compensation,
will do the work,and the swcture is nutintended ora@red for sale(Sec.10,14.Business
and Professions Com;no Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves daemon,and who doessuch warkhimsel(orlhrough his
own employees,provided that such improvements are not intended uroffered formic.It,
however,the building or improvement Is sold within one year of completion,Bahamas.
builder will have the burden of proving that he did not build or improve for puryou of
ale.).
0 1,as owner of Ne property,am exclusively contacting with licensed contractors to
construct the project(See.7&f4,Business and Professions Code:)The Comment',U.
on.Uw donna "I wan mvnor o(propeny who Wilds orinfamns thatch,art .
who contmcu for eb circus with a contractor(s)licensed pursuam w the Contractor's
License Law-
Kim
axe Sec. B,4 PC for this reason
0 nor Doe -900
'S COMPENSATION D C R ON
1 h by affirm under penalty of perjury one of the following declarations:
I have and will mainuin a Cenifcam ofContinua self-insure for Workers Cumpcm
sedan,as provided for by Scction 3100 of Ne LaWr Code.for the performance of the
work for which this permit is issued.
❑I have and will maintain Wurkcr's Compensation Insurance,as required by Section ,.
37M of the Labor Code,for the penormance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Wcumpleted ifthe permit is frronc hundred dollars($IW) _
in loss.)
I certify Ont int perfomwnce of the wn�Jri�rfor which this permit Is its ad.I shall not
employ any person' an man crs az /r m cob'. Yar ceri Compensation
Law,of Calif. ,
ApPlica t _
NOTam APPLICAtdii, kin s enifcam of Exemption,yno should
Wcome cn th rkcr' Compensation provisions of the Labor Code.you must
.J O forth comply with such provision or this Permit shall be decmrn revoked. -
'� 51 CONSTRUCTION LENDING AGENCY
[-a ti Ihemby affirm that them is a coruwctinn lending agency for the Performance of
!Yi the work for which this permit is issued(Sec.3091,Co.C.)
W� Q Lender's Name
z Lender's Addross
V O 1 certify that 1 have read this application and rude that the above information is
V, H eoneeL 1 agree to comply with all city and county animation and state laws relating to
0 U building construction,and hereby authorise mpresenutins;Of this city to ctikr upon Ru
a above-mentioned properly for inspection purposes.
(Wc)some to save,indcmmfy and keep harmless the City of Cupertino against
o-Fr y liabtldcn,j m ,costs and capenser which may in any way accoc against raid City
APPLI q c f ERS , ,ifiris! WILL COMPLY W 7TH A L N N POINT Issued by: Date
So,
TION
Re-roofs
naw of ApplicaMContrxctor _117"W4 Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haysrdouf national
az defined by Ne Cupenino Municipal Code.Chapter 9.12,and the alth and Safety
Cod.,Scction 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑res '�Na P P Y g g installed.
Will the applicant or future buil a amt Jcvion which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamnous air cumaminanuazd to ty nagcmenl all new materials for inspection.
Dinlrict0 ,/
Yes 74 N
IhaASf� O4.m
anhaterialsroquire uundcr Chaptn695ofdte CxdEm.
nia Hc,lth tl25N)5,2 2.1Ln anJeraundthatif the Willing
ocs not cem,th 'ty to notify the wmuPmt of the
requiremense cof.camficaa,or. a Signature of Applicant Date
Owner t rrrcJ agent I Dare All roof coverings to be Class aBa or better