05030207 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACT0R�INFORMATIOe-
N
BUILDING ADDRESS: DAVID VALVERDE PERMIT'%5030207
OWNER'S NAME: PERMIT ISSUE DATE
AJAY AT
E: SANITARY NO. CONTROL NO.
(408) 205-1376 1
wRCHITECiIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTORS DECLARATION Job Description
in� I toothy IMM that I am licensed under provisions of Chapter 9(commencing y,/�
r= with Seetion 7M))of Division 3 ofthte Business and Professions Code.and my 1'..is �KI n-x.
„ imm�mrt anaercec` TRUSS CALCS
m v4 z License Class Lie.9
arc Dam rosew,
SDECL NO NEW PERMIT ISSUED/ORIG. #04100156
ARCHITECTS
I undcnond my plans shall M used ss public records
U,
D
u Lwcnsed Pmfcssional
D OWNER-BUILDER DECLARATION
3 I hereby affirm Nal I am exempt from tho Contractors License Law for the
O o following reason.(Section 7031.5.eusimess and Professions Code:Any city or county
m which requires a permit to construct.aper,improve,demolish,or repair any structure
poor to its issuance.also ox rims the applicant for such permit to file a signed sm tment
tai thatheislicensedpursuantothepreAsionof0.Cootracmr'sLicenselaw(Chapter9 Sq.Ft. Floor Area Valuation So
'N$ (commencing with Section TIDO)of Division 3 of be Business and Professions Code)or
_ that he u exempt tMscfrom and the huts for the alleged exemption.Any violation of
Section 7031.5 by azry,applicant fon permit subjects the applicant to acivil penalty of ApN Number Occupancy Type
not mare man fin hundrod dollars(S500). 35924053 . 00
❑1,ss owner of the property,or my employees with wages u their into compensation,
will do to work.and the$.more is not iumnded or offend for ade(Sec.7(16,1,BusinessRaired Inspections
and Profession Curb:Code:TM Conuamors License law docs not apply m an owner of e q P
property who WHO;or ionvovethenon,and whodoesuch work himulfordtmugh his
Own employ=.provided Nat such improvements an,not intended oro@red Rogge.If,
howen,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.). t f�
0 h u owner of the propenX am exclusively contracting with licensed contractors to �l
construct Use pmjem(Sec.70,14.Business and Profession Cade:)TM Congumm't Li.
cerse law does not apply m an owner of property who Wilds or improve thereon,and
who contracts for such projects with a contrvetm(q licensed pursuant in Ne Commerce.
License Law.
❑ l am exempt under sec. ,B&P C far this moon
Owner Dam
WORKERS COMPENSATION DECLARATION
410 1 hereby aRtm or&,penalty of perjury not,of Me following dedgathim:
0 1 have and will mainoin a Ccrtificam of Cansem to self-insure fur Worker's Compere
anion,n provided for by Section 3700 of the laWr Code,for the perfommoce of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as mquised by Section
3700 of Ik labor Code,for Ne peRormanee of the work Our which this permit is issued.
My Workers Compensation Insunntt carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS' '
COMPENSATION INSURANCE
(Thissenion need not he completed if tie permit Is form=hundred dollars(51(1(1)
or kssl
I cemi'v Nat in Oc performance of the work for which this permit is issued.l shall not
employ any person in any manner so az to kcomc subject to the Workers Compenation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject in Nc Worker's Compensation provisions of Nc Labor Code,you Mug
.Jz forthwith comply with such provisions or Oil permit shall be democd tovokcd.
zCONSTRUCTION LENDING AGENCY
[�� I hereby affirm Nat None is a construction lending agency for the performance of
E
thc work for which Nu permit is issued(Sec.3097,Civ.C.)
(A 0 lender's Name
G Lcnder's AddxUg
U O 1 certify Nat 1 have read Nis application and sone that the above informau m is
U.r cmrem.I since to comply with all city and county ordinances and state laws relating to
0 building consWction,and hereby authomc npreenmtiws ofthis city to enter upon the
ra aWve-mentioned POrmy for inspection purpoms
(We)agme in save,indemnify and keep harmless on,City of Cupertino again.
F'y Iiabilidn,judgmcnes,costs and nponsu which may in any way attruc against good City -
U z in
eof the granting of UNDERSTANDStAt
s Permit.
LICAAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. S �
Re-roofs
HAZARDOUS
Signazun of ApplicaDa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the aapplicantCupen or forum building occupant dare or handle h Health
and Safety ss defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to an roofing material being 0 N
Will thea Ream or future building occu ant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
pp 6 P Area
n
emit hanNnm air contaminants u dcfimd by IM Bay Arta Air Quality Management all new materials for inspection.
District'
❑Yes ON.
I have read the harardous materials roquimments under Chapter 6.95 of he Califor.
Iia Health&SafmyCode,Sccuon n!K15.25533 and 25534.1 uedersoM thus ifthe Wilding
does Ips currently hale s tenant that it u my maponsihility to Wait,ft attupam of the
requirements which in=kmet poor to Issuance ofaCcrifieateoracupan. Signa re of Applicant Date
Owner nuthoriwd agent Date All roof coverings to be Class "B" or better