04070196CITY OF CUPERTINO'F='"�"
d".';
BUILDING DIVISION PERMITCONTRACT�WOR
INF t, ATION
BUILDING ADDRESS:
21499 17AT AVE
C & C VALLEY CONST.
PERMIT NO.
04070196
OWNER'S NAME:
PERMIT MUB DATE
Y @
SANITARY O. ROL NO. .
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO,
-
-
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACIOR'S DECLARATION
lob Description
1 hereby affirm Nal 1 m hemmed under provisions of Chapmr 9 (commencing
p
with Section 7(X of Division Sof the Business and Professions Code, and my luens is
Licen.seC mdeffCC1' Lie.0
REVISION --PORCH
Date Comoctm
NO NEW PERMIT ISSUED/ORIG. $04070196
ARCHITECT'SC.DECLARATION
1 understand my plans shall he used as puhiic records
Licensed Profcsstonal
OWNER -BUILDER DECLARATION
1 hereby alTrm that 1 am exempt from the Contractors License Law for the
.
following mason. (Section 703 1.5, Business and Professions Cade: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior toils issuance, also requires he applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuati(I115
that he is licensed ..moans to the provisions of she Cmflmcmr's License law(Charter 9
(commencing with Section 7000) or Division 3 of Ne Business and Professions Cook) or
Nat he is exempt therefrom and the basis for the alleged exemption. My violation of
APN Number
OccupancyType
YP
Section 7031.5 by any applicant for a permit eubjau
U the applicant pcnaltyaf
netmart than five hundred dmlars(5500).
❑I.uowner of the proprny, or my employees with wagesu their sole compensation,
36205022.00
Required Inspections
will do the work, and the swctum is not intended oroQcred forage Dec. 7044, Business
and Profee com Cade: The Contractor's Liam Law does not apply N an owner of
e ns
q p
property who builds or improves thereon. and who dauuch work himscif or through his
awn employees, provided that ouch impm,enoma ..or intended or offered for able. If,
however, the building or improvement is sold within one year of completion, the owner"
will hers the burden of proving that he did not build or improve for purpose of
Ile
\builder
sale
u Owner of the pmpeny. am exclusively co oraeting with licensed contractors to
0'd
(�
fir
the project (Sec. 7044. Business and Prafeviom Code) The Commences Li.
cense Law does not apply to an owner of progeny who builds or improm thereon, and ,
aft
who contracts for such projects with a contractor(s) licensed pursuant o the Contractor's
License Law.
❑lam exempt unddd��g ce P C
P C for
0 err .� ' Dake
Ga.
WORKER'SNPkINSATIONDECLAROTIOfAt
1 hereby affirm under penalty of perjury one of the following declarations:
lam and will maintain a Cerufiao om ofCment self-imum for WorkeYa Compere
,
,n, u provided for by Section 3700 of OR, Labor Code, for the peAormana of she
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of Ne Labor Code. for the performance of the work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number are:
Cartier, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(Thu It. beed not be completed if the Permit itfmmm hundred dollars ($100)
Or los)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mannerm as to become subject a LOU Wmkerf Compenation
Laws of California. Doc
Applicant
NOTICE TO APPLICANT: If, aper making Nis Cenifiale of Exemption, you should
become subject to the Worker's Compeuation provisions of the Labor Code, you mwt
foMwith comply with such provisions or Nis permit shall be deemed mvoked.
CONSTRUCTION LENDING AGENCY
thereby affirm that there is a construction lending agency for Nc perfurmarw of
be .,it for which Nu permit is issued (Sec. 3097. CO. C.)
Liader's Name
'
Under's Address
P certify that 1 have read this application and Dote that the above infmmation is
correct. 1 agree In comply with all city and county ominan ms and Doo lawn relating to
building construction, and hereby authorise mrocsenwaves of this city In enter upon the
above"mentioned Ropcny for inspecuan purpeua
(We) agree to save, indemnify and keep harmless the City of Cupcnino aSai011
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of Ne granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH Af/},. NON/s_p01
Issued by: 4De
SOU R�CgUL Np S.
L
G)
j�OI
Re -roofs
Type of Roof
Si ore of AVVp
u^tree tOr / e
- RAZAUS MATERIALS DISCLOSURE
Will Phe applicant of future building occupanutore or handle harardom material
as defined by the Cupenino Municipal Code, Chapter 9.13, and the Health and Safety
Code. secdon:ssli(a)?
All roofs shall be inspected to any roofing material being installed.
] Ya
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or furore building occupant use equipment or devices which
harardou it contaminants u efircd by the Bay Arta Air Quality Management
all new materials for inspection.
ice?
❑ Yes No
1 have read the havardous materials requirements under Chapter 6.95 of the Califoo
,
nix Flralooks cryCode, Secdoos M5,25533.d25534.1um mrd Nmif the Wilding
dm not cu ntly a tenana that it u my responsihiloy In notify the occupant Of OR
reymmco lC o" Ise met prior m issuance of a CentraleQcupancr'
Signature of Applicant Date ,
All roof coverings to be Class "B" or better
0wner or dagent
trn7 „e