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CITY OF CUPERTINO
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MMATION,
BUILDING DIVISION PERMIT
; CONTRXcTOR I�NEO ; :
BUILDING ADDRESS:
PERMIT N0.
SC BUILDERS INC
04080234
eRE3H BR
AM
PERMIT ISSUE DATE
E:
SANITARY OL NO.
ARCHITECT'/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRd under SDECLARATION
I hereby affirm that I am Y (commencing
pxd Prof of C
Job tl
fticBu lilt oomr
with on9ilxffcf Divieion3of NC Busircsx ark Prof gs Code��m licevc ix
in full f and effect. /e) J
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TI & UPGRADE (/`
Licem lass Lipp
Date Condr}rascp0�
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FEB Z 2005
Licensed Professional
OWNER -BUILDER DECLARATION
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mumu Licew
that I am exempt from on Contmaoo License Law for the
n exempt from
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Ig p n S
C's
.ififirmSect Pmf y city county
following mason, Section ]I13
f
�9`Ip11
which meaves a permit a construct, alter. improve, demolrh, or repair any museum
\nY/n (r,S 11911
i ensed P also mgolm3 SIM .pions o foe Such permit l0 EIC s Law (Chapter 1
punt m s licensed
he
Sq. Ft. Floor Area
- Va sea ton
(that
commexcanscdpuutramto 7001))ofa oftheButwat:uaenuvw sCous)rY
thammene sem it therefromon Cmla)of
the in Buainexemptoestand n.fAny
'
and vi
therefrom and Ne beer far the caseation. Any violation of
Nat W u ui3
eI
3 ���� O O
Occupancy Type
P Y YP
subjects
31.5 b arryapplicamrs(SS for a mbjccu the applicanuo.civil penalty of
not more man Eve handrail dollars (1500).
not mom than ).
.
El 1, as owner of drc property, or my employers with wages as them sole compensation.
will do the work and the someone is nor intended or offered for Sale (Sec. 7061, Business
Required Inspections
and Professions Code: The Contractor's License Law does non apply to an owner of
propeny who builds or improves thereon, and who doessuch work himself or through his
own employcca, provided that such improvements an notinundell or offered for sale. If.
however, the Wilding 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
.1c.).
C3 h as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7)61, Business and Professions Code:) The Contractors Li.
come law does not apply to an owner of property who Wilds ori Maidens menton, and
who contracts for such projects with a contra ter(a) licensed pursuant o the Contractors
License law.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of pordary one of the following declarations:
ban and will maintain a Certificate of Consent M snif-m ore for Worker's Compen-
mn. u provided for by Section J]00 of the labor Code. for me peRormaooce of me
work for which this permis is issued.
1 ban and will maintain Workers Compensation Insurance, as required by Section
,
l]I Of the LaborW p
labor Code, for tceforrumee of me work for which hits Permit iissli'sssuadt.
ly_CERTIFICATEOFEXEMPTIONFRf7
Ca errkl%�N'ensa�on ens Ct^ polcyoNo. nWCro`I' y—v
WORKERS'
COMPENSATION INSURANCE
('Imis section need not W completed if the permit is for one hundred dollars (IIM)
car It .)
I certify Nat in the performance of the work for which his permin is issued, 1 shall nut
employ any person in any manners, as to become subject to the Workers' Compensation
laws of California. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of on, labor Qke, you must
forthwith comply with such provisions or Nix Permit shall W deemed manked.
CONSTRUCTION LENDING AGENCY
I hemby affirm that here is a construction lending agency for he performance of
the work fur which this permit is issued (Sec. 309], Civ. C.)
Lamice,Namc
Lender's Address
I certify that I have fad this application and sure mat the above information is
conte,, I agree to comply wih all city and county ordinances and sur laws o lacing to
building concoction, and hereby aumofia representatives of this city to enter upon the
atwvcmemioned property for inspection purrows.
(We) agree to save, indemnify and kap harmless On City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue agamer=to City
in consequence of One grand ng of this Permit.
APPLICANT UNDERSTA j AND WIL CO Y WITN7n.L NONPOINT
% �
Issued by: Date
SOURCE REG ATI, Y
Re -roofs
Type of Roof
1/ �(/ iGta6/ /An 5'
Signature of ApplicmVComractor Dan
HAZARDOUS MATERIAL ISCLOSURE
Will the applicant or future Wilding acuPant store or handle hvardoux material
as dented by he Cupertino Municipal Cods. Chapter 9.12 and the Health and Safety
coda, Seedim 25532(.)?
❑Yes [f No
All roofs shall be inspected prior to any roofing materialZ�ng installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will he applicant or future building =upon( use equipment or devices which
hazardous air contaminants m defined by the Bay Ana Air Quality Management
all new materials for inspection.
ict?
0Yesu
I have mad me hxamd,us mauriau mquimments under Chapter 6.95 of the Calirm.
One building
25534. 1 unsNrsmnde Willing
car HealthurSafety Code, Sememtsied
Joewtcurrently haveatartan,, hat itr55raid
it i Mytwm1255J4,l
annotifyduaif
dexap fine
rcquioramis which nun /WmatpZssrareea c t of Occupancy.
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Signature of Applicant Date
iii-�`�" 5-13-0)
/
All roof coverings to be Class "B" or better L
g
Owneror authomcd agent Dam