04040019 CITY OF CUPERTINOx + wa
BUILDING DIVISION PERMIT kXONTRACTOR1INFORMATION $g
BUILDING ADDRESS: LINDA LAINE PERMIT"®4040019
OWNER'S NAME: PERMIT ISSUE DATE
ATNF, 10660 ARV 05/07/2004
;E: SANITARY NO. CONTROL NO.
(408) 996-2670
7ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONJob Description
I hcrcby afrrm tWt 1 am licenxcd under prvisions of CM1apmr Y(cnmmcncingcnion.7")of Division Sof Nc Business and Profession Code.md my license is
fora and eReatADD 1428 SQ.FT/GARAGE 416 SQ. FT.
,Ejse Clsss Lic.g
Dow Contrscwr
ARCHITECTS DECLARATION
¢ I understand my plans shall W used as public reeoms
JyU
3a.t; LiccnseJ Professional
S OWNER BUILDER DECLARATION
.�nE IW¢hyaffirm
on I1. exempttrainsan the Contracwo License Law corthe
ny
_p O following reaaon.(Schon 11131.5.Business and improve,
derom Code:Any city or county
m which requiras a permit to mm t et.alter,improve,demolish,or e a sig ed svucwn: $220000
Zi
prior or incense pursue,also ant
to the the applicant forsucthe Contractor's
cense signedstatement
that me ccensedPSectio 7 meofDivision3NeConusinss ndProclsw(C odrer9 Sq.Ft. Floor Area Valuation
YFO
(commencing with Senion7110tths Division she
taeeged ex and Professions Code)or
i�$ that k u exempt merefmrn and Ute beau for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subja.the applicant in a civil penalty of 3 7lPD�iOccupancy be10 0 OType
oat mom than five hundred della,,lisoo). P Y YP
0 I,m owner of the pmpeny,m my employees with wage u trek sole compensation,
willdothework,end Neswcsumisnotinmndedmofferedforsalc(Sec.7 a.BuMems;
and Professions Cade:The Contractor's License Law dors not apply to an owner of Required Inspections
property who Wilds or improve thernon,and who does such Work himself or through hisrowI�
honemplayeWildin i or imrovemimpmvem wsve not earocompltion.ed orofferned for eramor, '' �I� /� 11 �D
howemp the Wildioidad pmuthimpssold cuumw no)eardcompletion.theowoef. Iu� V\\V��!////-\\�\t 111'L�
builder will have tw burden of proving Nat he did not Wild or improve for Purpose of
e.).
C)I,as owner of trc pm ori,,am exclusively contracting with licensed contractors to
construct the pmjcer(Sec.7G&L Business and Professions Code:)The Contractors Li. CFP 2 O 200
ecru Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such pmjecta with acontracwr(s)licensed pursuant in the Contractors
License law.
t/❑ II NG
Sam,exert under Sec. B&P C for Nis moon
mss' r— ata
WORKER'S COMPENSATION DEC TION D
1 Wreby affirm under Penalty of perjury one of Ne fallowing declarations:
�+ I have and will maintain a Ccraficaue of Consent to ulf-insum for Worocescompem
ration,as provided for by Section 3100 of the Labor Code,for me performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as mquined by Section
3700 of me Labor Codc,for too Performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thuscction reed not W eomplered if the permit is fm one hundred dollars($1007
or less.)
1 ccni fy that in the performance of the work fm which this permit is issued.I Nall not
employ any person in any maruwr an as to become subjecna tW Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenificaw of Exemption,you should
become subject in use Workers Compensation provisions of me Labor Code you must
.,O forthwith comply with such provisions or oris Permit mailW deemed revoked.
Z"� CONSTRUCTION LENDING AGENCY
[—rte I hereby alTam that there is aconcWttinn lendingagency for the perfurma.or
!x the work for which his permit is issued(See 3097,Ci,C.)
Lenders Name '
=z Lenders Address
U Q I cenify that 1 have read this application and shote that the above information is
f" correct.I agree to comply with all city and county aNromeas and sure laws relating w
O V Wilding construction,and hereby aulhorim representatives of this city to enter upon we
r Ea above-mentioned p.Nrty for inspection purPosea.
F M. (We)agree to save,indemnify and keep harmless the City of CuPcnino against
to Liabilities.judgments,toss and as,.which may in any way secret against said City
U Z in consequence of the granting of this Permit. G
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE RE9DLATIONS. 5/7 O�)
{ Re-roofs
satire afAppl'oaHAZARDOUS_ MATERIALS DTSCLOSUAE�u tor Data
Type of Roof
Will dm applicant or future Wilding occupant Mort or handle havardous matanal
as defied by the Cupertino Municipal Code.Clasp e,9.12,and the Health and Safety
Code, 0ye.25532(e)1 All roofs shall be inspected nor to an roofing material being❑Yea �Na P P Y g g installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.B nmamour air contiminans as turned by the Bay Area Air Quality Management all new materials for inspection.
.buict?
Oyes Rho ^'
1 have real on hmzrdouss materials mquircmenu under Chapter 6.95 of the Califon
nut Health hk SactyCoude.Sectors 25505.25533 am12553a.l underrund this if the Wilding ;
dZN
wt currently hove a tenant that it is my responsibility w notiry tW occupant of the r
requimmcns whmh Wmapporwissuanecora Ccnifcateof Oce panty, /
` `� i_ �Y/,r b � Signature of Applicant Date
Owneror o<riacdxagen_t Data All roof coverings to be Class"B"or better ✓✓✓