04050177 CITY OF CUPET CONTRACTOR
BUILDING DIVISION
slon PERMIT �...< �
BUILDING ADDRESS: ALVAND CONSTRUCTION PERMIT NO.
04050177
OWNER'S NAME: ., PERMIT ESUEDAT6
Ahkk ESTATE FIN SANITARY 12 OL NO.
ARC HITECnENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Loo LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby afNm that turn licensed under provisions of Chapter 9(commencing
with
Section 70M)of Division 3 of tiro Bunnessand Professiom Code.and my license is
mmBmmeanaerceCL REVISION--IN HOUSE USE ONLY
5 to Z
Lice
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'3 u9Dam contractor NO NEW PERMIT ISSUED/ ORIG. #03040086
ARCHITECTS DECLARATION
�i 1 understand my plans shall W used as public records
7 U CI
C Licensed Professional C
8 OWNER-BUILDER DECLARATION �\
1 heathy affirm that I am exempt from Ne Connector's License Law for the
F.a o following mason.(Section 7031.5,Business and Profesamers Code:Any city or county S
a$ which requires a permit bs Constrct,alma Impmm,demolish,at repair any stmcwm
rZa
prior to I%issuance.aim requires the applicant farsuch permit 10 file a signed nammont
Fxx that he is licensed pursuenttothe provisionsofthe Contemanr'sLicense Law(Chapter 9 Sq.Ft.Floor Area 1H 32
NO (commencing with Section 7")of Division 3 of the Businom and Professions Code)or -
ey that he is exempt tMmfmen and the baa6 for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mom than lova hundred dollars(SSWy 35601051 . 00
❑I,as owner of the property,or my employes with wages as limit compensation,
will do the work end the swmure is not intended or offered for sale(Sec.7044,Business
and Profess)mu Cc&:The Contncmr's License Law does not apply to an owner of Required Inspections
progeny who builds or improves thereon,and who does such work himself or through his
mvn employees,provided that such improvements are notimmnded aroffercd forsale.If.
however,the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
reit.).
pq 1.as owner of the progeny,am exclusively contracting with licensed canvactma to
construct the project(Sec.7044.Business and Promsvans Cade:)The Contractors Li-
cense law does not apply to an owner of property who Wilda or improv.¢themon.and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑'/19e/�r eat untler Sec. 1•,,` .B&P C for Nis recon
O`' �ERS OMPENSATIONDECION
I hereby aRmm under penalty of perjury ON of the following declarations:
have and will munuis a Certificate ofConsem to self-intim for Wormer Corona.
redo.,es providca for by Section 37W of the Labor Code,far tiro fmmem perof the
work for which this permit is Issued.
❑1 have and will maintain Workers Compensation Insurance,a required by Section
37W of IN Labor Coat,for the performancce of the work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number w:
Carrier. policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITlssecticn need malsocomplemd if the permit Is Wrmal undreddollam(SIM)
or leas.)
I certify that in the performance of the work for which this Formal is issued,I shall not
employ any person in any manner so e in hecome mbject to the Workers'Compensation -
Laws or California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Came,you most
.J,7., forthwith comply with such provisions or this permit shall W deemed invoked.
ti O CONSTRUCTION LENDING AGENCY
En Iherehy affirm that them is a construction lending agenry,for the performance of
[� > dm work for which Nin permit is issued(Sec.3099,Civ.C.)
W Q Lender's Net.
Lenders Address
[� 1 certify that 1 have read Nis application and sato that the be.information is
W F curtain 1 agree to comply with all city and county ordinances and slam lawn relating to
e
C.)
building consuuctiomand hereby
ection prposesenmlivrs of this city to Color Upon dm
W shove-mentioned aproperty1...for inspection purposes.
0) (We)ague to save,indemnify and keep hay in m tiro y m of mCupertino id Cit l
Uy in Coisiequence of
gratsing oxpenmsmiich may in any way eccmc against mid City
C)7 APPLI ANT or UNDERSTANDS
of thisDWil.
r7 APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS r
��1,�U � Re-roofs r
Sign,at of Applicanr/Comracmr '�-gym e of Roof
HAZARDOUS MATERIALS DISCLOSURE Typ
Will the applicant or future building occupant store or handle hauudoes material
as defored by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yrs Nu
(.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haaamnus air contaminants as deOned by the Bay Arm Air Quality Management all new materials for inspection.
U District?
❑Yrs \C:41No
I have mad Ne hasardnus materials mquimmems under Chapmr 6.95 of the Califor.
nia Health&Safety Coda,Sectioe 25505.25533 and 25536.1 understand that If the building
dace not currently have a tenonsthat it is my mspomihility in notify the occupant of the
mquimmena which must met prior to issuance or a Ccrdfiasm of Occupancy. Signature Of Applicant Date
O mer or authorized agent Oam
All roof coverings to be Class"B"or better