03110143 CITY OF CUPERTINO °
BUILDING DIVISION PERMIT CONTRACT OR ANF,OR1VIk1T�ION, ,>
BUILDING ADDRESS: DRAEGER CONSTRUCTION INC PERMIT Nofl 3 110 14 3
� 47 STAFFORD DR
ERS NAME: PERMITLSSUEDATE
CAROL PARK 605 COMMERCIA ST 11/24/2003
PHONE: SANITARY NO. CONTROL NO.
(408) 536-0420
ARCHITECrIENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
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�Op LICENSED CONTRACTOR'S DECLARATION lob Description
I I hcrcby affirm that I am licensed under provisions of Chapter 9(commencing P
nil with Section 70(10)of Division 3 of the Busineuy1re Proposal..Cele.and my license is
infail(a effect 3 Lie.✓ (� f�4f V REPLACE DECK DAMAGE .& BROKEN CHIMNEY
License Cl
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iLicensed Pmfcssional
OWNER-BUILDER DECLARATION
<n I hereby affirm that I am exempt from the Contractor's License Law for the
COO following mason.(Section 7031.5,Business and Prorcaiom Code:Any city or county
which requires a permit to consumer,atter,improve,demolish.or repair any mucrons $10000
4$- prior I.its iam.nec,al.uraquims thaapplieam forsuch permit to file aligned statement
C that W is licensed pumuanl to the provisions of the Commcmr's License Law(Chapter 9 Sq.FL Floor Area Valuation
$ (commencing with Section 7600)of Division 3 of the Business and Professions Code)or
that he is exempt thamfrom and Ne basis fur Ne alleged exemption.Any vinlatioa of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 i5,PIR e. O Occupancy Type
not marc than five hundred dollars(5500).
❑1.as owner of the pmpwy,m my employees with wages a their sole compensation,
will do Ne work,and the structure is not intended or offend far sale(Sec.7044,Business
and Professions Cade:The Contnemr's License Law dose nor apply t.an..all of Required Inspections
property who builds or improves thereon,and who does such work himself orthrough his
own employees,provided that such Improvements are not intended orolremd fertile,If,
however,the building or improvement is sold within one year ofcompletion.the owner,
builder will have the burden or proving that he did not Wild or improve for puryose of
sale.),
Q 1,as owner of the property,am exclusively contracting with Beensed contactors m
eomtact the project(Sec.7044,Business and Professions Code:)The Contractors U.
teas law does not apply to an owner.(progeny who Wilds or improves thcmon,and,
who contracts for such propos with a contractor(.)licensed pursuant to the Chronicles
License Law.
❑1 am exempt under See. .B&P C(or this moon
er Data
WORKER'S COMPENSATION DECLARATION
I hereby&(firm under penalty of perjury oro of Be following declarni.m:
❑Thaw and will maintslna Cenlfiateof C.menu.sel6insum fw WorkeM1 Compcm
.ation,as provided for by Section 3700 of the labor Cade,for the performmro of the '
work for which this permit Is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,a required by Section
3700 of Ne labor Code,for Ne performance of the work for which this pmoh Is Issued.
My Worker's Compensation Insumnm carrier and Policy
11 number am:
4
a rtcfi f n/S. CC. PaIigtl C- WC— IC-e`2
CERTIFICATE OF EXEMPTION MWORKERS'
COMPENSATION INSURANCEt-,�fy A/OV 2S-12 ej
(This section need not W completed if tax Permit is for one hundred dollars(SIM)
car leas.)
1 cantly that in the per0nmaace of Ne work for which this permit is Issued,l shall nut
employ any human in any manner sat as b become Subject to the Workcn'C.mPenseOon
Laws of California.Data - -
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Fmmpioa,you should
become subject to the Workers Compensation p oolsions of the Labor Code,you a=
JZ forthwith comply with such Provisions ss.his Permit shall W accrued revoked.
Z'"� CONSTRUCTION LENDING AGENCY
I Whxhy Affirm Nat Here is a contwctlnn lending agency fm the performance of
D'.
to work for which this permit Is issued(Sec.3097,Civ.C.)
Lza Q Lender's Name
z Landers Address
U Q L coolly that 1 have mad this application end slam that the above inform W ua Is
I7r F
compel.1 agree to comply with all city and county ordinances and some laws mining to
QU Wilding conswctian,and hereby authorne mpresemadves of this city to enter upon the
W above-mentioned property far inspection purpmea
(We)agree to ague,indemnify and keep haonlea the City or Cupertino against
,.t Cn liabilities,judgments.costs and expenses which may in any way accrue arms,said City
f) In consequcn of rhe gm I'd "(this Permit.
APPLICA UNDERSTANDS AND WILL C(tMPLY WITH ALL NON-POINT Issued by: Date
SOURCE EGULATIONS.
Re-roofs
gra ore of Applin HAriTC ZAone RDOUS MATERIAL DISCLOSURE Date Type Of ROOF li
Will the appll,anL or fawns Wilding amp,mature or handle haamoua material
defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safely
a.Se❑clti s 25532(.)7 &N. All roofs shall be inspected prior to any roofing material being installed.
Win the applicant or furore building occupant use equipment or device.which If a roof is installed without first obtaining an inspection,I agree to remove •
emit harallous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Disviel? i
C]Yes a.FrNir -
I have med Ne hemodous materials¢quirements under Chapter 6.95 of the Califon
nil Hwnh&Safety Code,Sections 255(15,75533 and 25534.T undcrsmnd Out,if the Wilding
docs not cu ndy haw a mnanl that it is my rosponsihility o nodfy tW occupant of thc
mquireman whichmunC sectpriarmissuence.fvoCcrditeat�ofOce an� Signature of Applicant Date
wn araamorima age¢ rote All roof coverings-to be Class "B"or better '