04040106 CITY OF CUPERTINO
BUILDING division PERMIT CONTRA CTOR,INFORIVIATION
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BUILDING ADDRESS: ABCO CONST PERMIT NO.04040106
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY iftOL NO.
linse
ITEC rENGINEER: BUILDINGPERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONI hereby affirm that I am ficencd under provisions of Chapter 9(commencing Job Descriptionhecti e'raid)of Division 3 ofthe Business ad Profession Code,nd my license isfora and cffmt.qClas Lic.Is DEMO (E) HOUSE
1 U Daly I understand my plans—Contractor
shalll he used aCHITECTS publicAe^O�N AUG.2j/ 2004
LLo y Licensed!Professional
OWNER-BUILDER DECLARATION sofa�B/f RT.jAO�
1 herahy affirm that 1 me exempt from Ne Contractors License Law far the abb(I�IGAtl
no following reason.(Section 7131.5,Business and pndessors Code:Any city or county
y$ which requires a Permit in construct,after,improve,demolish,or repair my structure
filaprior to its issuance,also requires the applicant for such permit to rile a signed sammcm
Out he is licensed pecmenuo the provision of Ne Conuanor's Lune law(Chapter 9 Sq.Ft. Floor Area Valuation
,FC (commencing with Section 7")of Division 3 of the Business and Professions Code)or
y
that he u exempt Nemfrom and No basis for the alleged exemption.Any violation of �y.�0}ai�5a�..,A
Section 9031.5 by any applicant for a permit subjects the applicant a civil penalty of 3 f-a�L^6lW.D W l O O
not moa Nan rive hundred dnnan(M). !1-p N24 a Occupancy Type
❑1,u owner of Ne pmwny,or my employee with wags m Noir sole comwnudon,
willdo Nework.end NaavuaumunotinlendedwaWadforsale(Stt.7 W.Business
and Professions Coda:The Co enmrs License law does not pply to an owner of Required Inspections
property who buildsorminnows demon,and who doessuch work himse1forthrough his
own employees,provided that such improvements as not intended or offered for sale.If,
however,the building or improvement is mid within ane year of completion.Ne owner-
builder will have the burden of proving that he did tot build m improve for purpose of
sola.).
)Rlj, owner of the property,704 am=elusivelyend contracting with:)The
convenors m
ca Tera the es not (Sec.too4a,owner
of and Profession Code i Tho Convamon. nd
ewer taw dors not apply a an owner of property who builds or improves thereon,end
whocontractsLacts for such projects with a eonvanar(s)licensed pursuant m the Convmtors
License law.
❑ Ionexempt under
/5/¢/.//)— .8&PCfor Nu rcawn
Ownvrn �x'j Q��i/��/'`- Com._.,aj[1/r F1
WORKERS COMPENSATION DECLARATION_/
I hereby affirm under penalty of perjury ons of the fallowing deck rmon:
aw and will maintainv Cenif teof Consentmself-insumforWorker'sCompnn-
satian.as provided for by Section 3900 of me laid,Code.far the Nifmadmix of the
work for which this permit is;ssued.
❑1 new and will maintain Workers Compemmim Inourna,as agNad by Section
37W of the labor Cale.for the performance of On work for which this permit is issued.
My Workers Compenuion Inaerana cmier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF FXEMPf10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not beeomPICled if Ne permit is for one hundred dollars($ftg)
or less)
I cen;fy that in the Performance of to work for which this permit is issued.l shall not
employ any person in my mnoer an as to became subject m No Workeri Compenabon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificaue of Exemption,you should
become subject to the Worker's Compensation provision of tbe tabor Code,you must
.,O forthwith comply with such provision or this permit shall be deemed revoked.
Z''—' CONSTRUCTION LENDING AGENCY
[-+� I hereby affirm that Vert is a convection fending agency for the performance of
Cm> Ne work for which this permit is issued(Sec.3099,Ch,C.)
D3 0 Lender's Namc
= z Underi Address
U Q 1 certify Nat 1 have read this application and sale Nu the show information It
fy F correct.I agree m comply with all city and county ordinntts and sate laws relating to
0 building construction,and hereby auNodm repasontativa of this city ed cnar upon re,
r shove-mentioned property,for inpcetion purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
(~ y habiloies,judgments,cosa and expenses which may in any way aecmc against said City /J
U Z in consequence of the granting of this permit arse(
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dae
SOURCE REGUL��,yWyDNS.
W/a' .tGz $//ff%!j� Re-roofs
Sig fAoplicnl/Convnmr
f� HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building dccupnl store or handle heard smaterial
u defined by Ne Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
GOdC.Section
rJ{Nion 25533(a)7 yyKyyyo All roofs shall be inspected prior to any roofing material being installed.
Y
S pp s w equipment If a roof is installed without first obtaining an inspection,I agree to remove
Will Nc applicant or future Wilding arta m use e t or devices which g
hannhous air conmminams a defined by the Bay Arca Air Quality Management all new materials for inspection.
evict? tv
❑Yes Ifgl No
1 have read the nevNtrosmalerials mquimmena under Chapter6.95 of Ne Califon
nia Flullh&SafclyCo lk.Sections 25515.25533 and 25534.1 undurswW Nuif tM building
does not currently haw a tenant that it is my neswnihility to notify the cupnt of the
requirements whiehmnt mnpriormi anaaIsCen&ateofoecvpncy. Signature of Applicant Date
tV>~ �� O 4.
ow aumodred oven mI All roof coverings to be Class"B"or better