04020102BUILDING DIVISION
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BUILDING ADDRESS:
ARCHI=f[INGiNEER:
JERRY ENOS
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fora and effect.
License Class Lle. 11 NEW WINDOW
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for Or
following reason- (Section 7031.5, Business and Professions Code: Any city or county
which requires a pernit to construct, alter, improve, demolish, or repair any sutrctutc
prior to its issuance, also requires the applicant for such pernil to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
rust he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars (5500).
❑ 1, 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 Contractors License Law does not apply to an owner of
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 Contractors 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.
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DECLARATION
hereby affirm under penalty of perjury one or1fie following declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
sadon, 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 Workers 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 arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars (S 100)
or loss.)
I certify that In the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT: If, after making this Ccnificatc of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construcdon lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ- C.)
Lenders Name
Lenders Address
I cenify 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 sate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the city of Cupertino against
liabilities, Judgments, coats and ex uses which may In any way acaue against said City
in consequenco of the gnnti permit.
APPLICANT UNDER ND WILL COMPLY WITH ALL NON -POINT
Will the applicant or future building occupant use equipment or devices which
it barsrdous air contaminants as defined by the Bay Area Air Quality Management
Itsu'ct7
[I Yes rrN.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaFlcalth&SafctyCodc, 25505,25533and 25534.1understand dutifLhebuilding
does not cuurently h t that it is my responsibility to notify the occupant of the
requirements soul be met prior to issuance of a Ceruh to of �,pancy.
Sq. Ft. Floor Area
311dq*e0 0
Issued by:
Re -roofs
Type of Roof
PERMIT NI. 4 0 2 010 2
PERMIT ISSUE DATE
SANITARY CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
Required Inspections
FINAL"78"C?
AUG 11 2004
BUILDIPVV J
Date
Type
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better