02020041 (RAMON
F CUPERTINO � " " 1• 1 '
BUILDING DIVISION pE CONTRACTOR,INFORM IONo-
DRESS: PERMIT NO.
r
ME: APPLICATION SUB DATE
ZOILA `J02 11 2002
/ SANITARY NO. CONTROL NO.
Q mZNGINEER: BUILDING PERMIT INFO
to
OBLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATIONJob Description
D Z- y afilem that Iam liccnxdunderprovisionsof Chapter 9(commencingyamwith Section](100)ofDivision 3of the IthadmsandProfewion.Code,andmylicenm ?,EMP GENERATOR.
xY I j is in full force and effect.
z ¢ Licence Clam Lle.Y
a O a U Data Contractor
+� O Fi: ARCHITECTS DECLARATION -
,� 1 under.mnd my plans shall M used as public records
i
v O O Licensed Pmfessionnl
OWNER-BUILDER DECLARATION
I hereby affirm,hat I an,exempt from the Contractor's License Law for the
N
C?G -following reason. Sectio7031.5,Businesnd Professions Code:' ciy ileor
c. which q permitmcma,mustidne,amprowe,do hilt ...' v sureco e
t t I q evPplca t forsuchnin g w(susternard
,
0._000
c. thatlie iii,lacentedImposing pambprro rte c trat r License Law(Chapter 9 Valu
(commencingati_o_.n'withSa rfvi 3 nn Rasmus andca)
or that he s tnyeRamand theb six for the alleged einnpnoij.goy violation 31'62 O 0 3 7""tIjLx
of Seamon 11.5 b any am fora Permit subjectthe applicant to acivpnalty-
..
.._..
urnrnmore than five hundred dollar, ssoo). APN Number 4 ,: Occupancy Type
01,as owner of the property,or my employees with wagesax(neirsoleeomucanumn, 304 - ROUGH ELECTRI A'L
-wll-d th rk:and the stmcmre is nor intended or offered'far sale(Sec ]014,' ---- - - - - -- - -- _ - -
Business and Professions Code.The Contractors License Law does not apply, an fl
wee,of property Who builds or mpruvex lowean and who dues each work himself 5 0 5 - FINAL E
of enough hissu own employees,provided that himprovementsarc o t intended or
offered for sole If;h the F Id' t p" mons -sold ithid one}ear of
improve fo•,ne owner sale) will have the burden of proving that he did not build or
improve for purpose of sale.),
i
pi- r of the Property, explosively contracting Withlicensed contractors t
instruct the present(Sec ]044,owner and Profess ons Code:)The Contractors ni
License Law docs not.suc [pan owner M property who builds ted ruminant to for
..end_who comra<ts.for such projects-with a.commaor(s)licensed pvrsnem tome 1
Contractors LicauseLaw.
OI exempt enders �'= BAPCfor mis meson ,: , l ��'.t
O nen ""Dora"
WORKER'S COMPENSATION DECLARATION
,
I hereby affirm under penalty of perjaiy one of the following declarations:-
1 have and will maman e'Cettifierne'ofContend,o self-insure for Worker's
=.`. Compensation;a, provided for by Section 37M of the Labor Code, for the
performance of the work for which,his permit is issued.
❑t have and will rkainhim W rker;s C moramanom Insurance,as required by Section
3700 of the Labor Cade,for,rte performance of,he work for which this per 1 is
inued:MyWorkir'sCompensati6nlnsunierandPolicinimberibe
_
a er 11/ oi¢y N
_.. NFC�S06G°E 16� 1 t
r r EXEhIPT10N FROM WORKERS I I i t S 1 Y r P(r t I j q
ER IFICAC COMPENSATION INSURANCE r
COMPE
' (Th et on need not be completed it the permit is for one hundred dollars 'I 't "'' ' t '-�'t {"Pt.
(S I yd)or loss'),
.. . .
i'. I c nit that in the erf ee of th work far which th¢
Y P perrti is issued I
shall not employ any person in any mander so as m become subject to the Weakers
Compensation Laws of California Date '
Applicantii _ i -.."._.... .. - .._
NOTICE TOAPPLICANT:If,after making
Q O " Workers Certificate Exemption,you should'
„ ,
become subject the Wo heC pens[ion provisions
fag Labor Coudeyou mus,
foh th mply'with such provisions or thus permit shall be deemed
evoked. '
H�y x"� '. +CONSTRUCTION LENDING AGENCY -, - ,
_ai 1 h b (Flrm met mere i e an w n n lend n nna c is', _ ,
W;� y p issued(Sea 109] C' C)
Leede Addrc. h th t
of me kfar he
Leede N me -
� z
.,0 I n fy tht I ha a d,h eppl a nd sm¢,hat the above mformatlon is
�T+.E,,, bd t 1,g <t comply ih 11 ciry a d ty ortlinances and xtete laws relating
Qcf,J rob Id g nsunctio dhby auN p eiitdtives of trap ciry to enter open
�af� �me ab- e l tined p p ny for inxpect p rp s.,_ .
y Ci' IWe)' ee,us dem ify vnd Ae ph I ss lheC tyafC pert'oeg firat
rr-VI lie Yl tet y, ngsof thrsg ndt' p'p;e nimaY.in anY Ya a often said
v za
'APpDIC U R$ lDS AND II ..... 'NhTH ALL VP INT r'
s uR c Issued by: Date
ig t r.mou Apps anUCo tin tor, m' Re-roofs
CWW1,he 'IHA manim bMdAnEoIALSDISCLOSURE Typeof Roof,..,, .::::, ..:- .•,.
a dell,ed th th Cu rt na M m i C d Cha ter 9 12 and th H ith-nd Safe
as
od Sen on 25532(x) No
PP g pant stole r handle hazard s matenal
DY a. t .. ' [a'AS tell t. T{ham
P p P Y
PP g P ' I X11 roofs shall be Inspected poor to_any roo£Ing,material being installed
Will thea applicant rfutu a building c use equipment n, device:which If a roof Is installed without first obtaining an•inspection I''agree'to remove
mentalran pf" y y AreaAr Quality Management ,
Olstnci ntam na is d m d b the Ba
El yet, read m No all non-point
for Inspection Applicant understands and will comply with
all new maters
Cahfomie Health&S , 9irements:under Chapter 6.
efet andl norc,25505:25533 and 25534.1 vnderst 011rCe regnlationS
t e hazard us Sof the '
Y and that; . ..._ ..._..__.. ......... .. .. _
I'll ti iltl %d eynol curtenay haveam gtha,iliamymspp aditytonotfythe; """'- - ..... "-' -- - - -
-6cc p n mer ast be met poo to issuance f a Certificate of:
fire , 1 h m„
0 nine.- c . . ..... ...... .g. . ._ �. ..
_Signature of Applicant Date
r or mo I I a t I o All roof coverings to be ClassB"or better
t
h - -..,...__OFFICE. ... . ... . " _....__ . . . ...__. _,... ... . .
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