02100082 CITY OF CUPEWHNO .�'r'"'°"+`�h +" a "•<' `+ aR %±
BUILDING DIVISION PERMIT W CONTRACTORaINFuORMATIO .,
BUILDING ADDRESS: CONSTRUCTIVE BUILDING SVC, "NIF"03100082
OWNER's NAME: 3937 39TH AVE PERMIT ISSUE DATE
RTTqTV DAY (4TT4 PT
!E: SANITARY NO. CONTROL NO.
(510) 531-1175
ARCHITE-C(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;00 LICENSED CONTRACTOR'S DECLARATION Job Description
{ 1 hereby snort that 1 am licensed under previsions of Chapter 9(commencing P
with Senion70w)of on3oflhe Busine and rofC., Code.andm 1' nm is /
in ruse forc�(m etrem. ti DEMO ^/
r 2 Licen"Class TSg t/
Dale C-mox`-
Q / ARCHITELTS DELLA
or hSm /
i l ex slant my plans shell W used u public c J
fy d
0� Licensed Pmressionel
5 OWNER—BUILDER DECLARATION
Contractor's
ON
0 f I ruroco effmm on I I.S.exempt from she Cssion Co License Law or the
-p O following mason.(Section 703 nstrBusiness and Improve.
dcunu Code:Any city or county
e m tea which rcyvs u a plait re areae,alcor,i t For su de ch Permit
t Fie a sig any structure
tpoor hat he its issuance.c,aluamto theres the
provisions
visio sof for Contrarmiuoiorme,Law
statement
(commencing
wJ puramano Division 3 of the BmLorinian"iumn(Chapter)or Sq. Ft. Floor Area Valuation
thammene seemwith Section anddrDivisiofrnrthceged ests and xempton.Any
or
$ Net he is exempt therefrom and Ne basis for the alleged exemption.Any violation of 36901019 . on
Section 7031.5 by any applioam for a anott Subjects the applicanuo a civil penalty of APN Number Occupancy Type
nor mom than five hundred dollars($500).
O 1,as owner of the property,or my employees with wages u their sole compensation,
will do the work,and the structure,is nos intended or offered for sale(Sec.7044,Businessand Prefessmna Cocke:The Cenuaeme.License Law does not apply m.n owner of — DEMO
Required Inspections
property who builds or improves thereon,and who deassuch work himulf or through his
Own employees,provided that such imp co menu we not intended or offered for sale.If,
however,Ne building or improvement is sold within one year of completion,the owner. _
but lder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
0 1,as owner of the progeny,am csclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Profusions Cade:)The Contractor's Li.
ccue Taw docs not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant o the Conuactor's
License La-
0 1 we exempt under Sec. .B k P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
7cly��:`, �
investor will meinuin a Cenifcam of Couem m ulGinsum far .Worker's CumPem
,u provided for by Section 7]00 of the IaWr Code.for the performance of sW
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,"required by Section
of the labor Code,for the performance of the work for which thiss pseerrol,I�,issued.
rance csmicr no Policy ryI r �kof Y1OFEb{. NM ORKERg'
PENSA NINSURANCE
(Thu section need not W compleed if rte permit is reeene hundred dutlm(SKXB
or Less.)
I ceniry Ihm in the pe,for n wc,of the work for which Nis Permit is issued.I shall not
employ any person in any manner an as In become subject to the Workeri COMICUNlon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenificatc of Exemption,you should
became subject to the Worker's Compeuarion previsions of the Labor Code,you must
�z forthwith comply with such Provisions or this permluhall he deemed rooked.
ZO CONSTRUCTION LENDING AGENCY
I Wreby affirm that them is a emuuuctinn lending agency ror the performance of
]v the work for which this permit is issued(Sec.3097,Co.Q
1QUnderi Name
:5z Under,Address
J Q 1 Certify Nat I have read this application and Stam that the above information is
y coned.I agree to comply with all city and county ordinances and State laws relating to -
�U building construction,and hereby amhOtiV MOICUMriwa of this city to enter upon the
NU .hove-mentioned pororty for inspection purposes.
0. (We)agree ro saw,iml fy and keep harmless dm City of Cuper,tno at
rn lobilitiu.judgmcn rad nsu whichmaymorywaywcrueagainnutd Ctry
:J z inconsequence e u this permit. (r9l
�w APPLR N AND WIL WITH ALL NON-POINT Issued by: ale
S EG 1 so
0 Re-roofs
Mori r AZA DOUSMATERIALS DISCLOSURE Dam Type of Roof
Will a pliant ser!Lure ilJing occupmtsmm ar M1armle ha"rdeus mamdel
u defined a Cupertino Mu cipal Codc.Chapter 9.t].and Ne Health and Safety
cwle,geek sslz(a>7 Nu All roofs shall be inspected prior to any roofing material being installed.
Witt the applicant or Lem Wilding occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
I havardoso air comamina defined by the Bay Area Air Quality Management all new materials for inspection.
tstricli
D Yes [D No
thaw W e Liu mrials ti oderChaPmr6.95ertWC.Idm-
nickHcalth arc ti snd25534.1 un@rsmnJ tharifthe Wilding
tines no, iA nilarca n t it is my res,.ihility m nodry Jan ottupmt nrthe
requirem orhma it, orOrissuance Ora Certific. nr a Signature of Applicant Date
Owncru orimd m m All roof coverings to be Class "B"or better