04080233 (2) CITY OF CUPERTINO .'» °
BUILDING DIVISION PERMIT ,CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NOO 4 0 8 0 2 3 3
OWNER'S NAME: PERMIT ISSUE DATE
lipE: SANITARY 90. CONTROL NO.
ARCHITECrrENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0 0 0
1100 LICENSED CONTRACTOR'S DECLARATION Job Description
in� 1 heti y efOrm that I em licensed under p ns of Chapter 9(mmmenc,. P
wishled . �40B`m Divixion3of NC Busi�pg5, r Prolessium Code,and myliccnscis
nPm inretireks andcff
5 Lkenw�C1. "�' Lie.g �-$ o S' DEMO (E) POOL
"-� Dain^ //— Comrannr CONTRACTOR: DIRTWORK UNLIMITED
ARCHITECTS DECLARATION
1 l„I��l. �
1 understand my plans dull he used as public mewls V 5 1 W(i
DyU
o G Liccnud Professional
3
OWNER-BUILDER DECLARATION
+� I beuny aRnn on 1 am exempt from IPr Canons Co License Law for the
i
00 following on.(section 70313.Business and Professions Code:Any city or county
X.96!
which requires a funis no mwract aloe imProw,demnlbh,lir lupair any sLmnulu
rZm prior to its issuance.also regains the applicant for such permit to rile a Signed summmt
ppmm< the,MislicensedpursuammrheprovisimuortheContracmhLicencelaw(Chapter9 Sq. Ft. Floor Area C. 111aluat,"200
rjF� (commencing with Section 7")of Division 3 or NC Business and professions Code)or
iWe
to
he is exempt delufmm and the basis for Ne alleged exemption.Any violation of s
Section 7031.5 by mr,applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($5M),
0 1.as owner of the property,or my employees with wages u their=it compcnsadon, 35701053 . 00
will do the work and dee swan.is of intended or Offered fanak(Sec.7W4,Business
and Professions Cade:The Contracuse,License law does not apply be an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees.provided that such improvemenuae not intended or offered for sale.If.
hawewr.to,building or improvement is to within one yea of completion,the owner-
Wimm will have ft burden of proving than W did rot Wild Or improve for purpose of
talc.).
0 1.as owner of the propeny,am exclusively contracting with licensed convectors to
construct the project(Sec.7044,Business and Profusions Code:)The Contractor's Li-
cense Law does nut apply m an owner of property,who W Rds or improves thereon,and
who contracts for such pmjem with a comador(s)licensed pursuant to the Conrs"Oes
License Law.
O l am exempt under sec. Bd:PCpar this reason
OwnerDau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dcelarstions:
have and will mainum a Certificate of Consent to self-insure for WwkeYs Compsn-
t37
,as provided(0r by Section 3700 of the labor Clot.for the perfomunce of the
for which this Permit is issued.
haw and will maintain Wmker's Compensation Insurance.u required by Section
of Ne Labor Code.for the performance of thework for which this pmmit is issued.
W sC mpcnse' Insulin carti Pulry n be art:
W ire. v 1 Cva
CERTI LATE OF E%EMPfION MWORKERS'
COMPENSATION INSURANCE
rIDisseetion need not he completed little Permit Is fwomebundred dollars(SIM)
or less)
1 certify that in Ne performance of the work for which this Permit 0 iuucd.)shall not
employ any Nixon in my manncfm u to become subject to tie Wmixecy Compcnsadon
Laws of Calif..!.Dau
Applicmn
NOTICE TO APPLICANT:If.after making this Cenificme of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
�Z row,wilh comply with such provisions or this Permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-r a 7 the wank1for whiacfhfithishPermit
u u isiusurocd(See..30n97.Civ.
gagcmy(lir the per
formarce of
C.)
III im Leroces Name
IY lender's Address
U 0 1 certify that 1 have read this application and sum that the above information is
correct 1 ague to comply with all city and county alinmm and sum laws peating to
0U building construction,and hereby mthorile sepnsenmiws Of Nis city in Oliver upon the
r{37 anew-mentioned plurally for inspection purposes
(We)agree to arc,indemnify and kcep harmless the City of Cupertino agorm
F'N IiabRidu,judgmenu,costs and expmues which may in any way acme against said City
Uz in consequence of the gratin this Permit.
APPLICA U ERST COMPLY WITH ALL NON-POINT Issued by: D
E C ATION
Re-roofs
Signature of Appliemo/ omuew Data Type of Roof
t lAZARIO' MA LS DISCLOSURE
Will the appmantor furor uildi o cupant store or handle hazardous maverial
as defined by the Cupertino Municipal d.Come,9.13,and the Health and Safety
Cour.Section 355334)" All roofs shall be inspected prior to any roofing material being installed.
0Yo
NB the applicant or future Wilding Occupant use equipment Or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
n held.'air contaminants u defncd by the Bay Ara Air Quality Managcrem all new materials for inspection.
aria"
E Yes No
lowmad Nebarallousm ialsmquimmcntsundcr Chapmr6.95ofdmCalifor-
nuFlcilthg:s9cycoM.Sadors 35505.r55Jlm 574.1unMnsuM thatiftbe Wilding
dao non curtcady wavers Wlit ihility
an marry the oceupou Or de
m mpabe prior eraCnificautofa Signature ofApplicant Date
mer pr aathpd..ed g t Dam All roof coverings to be Class"B"or better