03100037 CITY OF CUPERTINOyrs w+,ii.,ro�, Oa9i ;
BUILDING DIVISION MIT CONTRACTOR INFORMATION a. _
BUILDING ADDRESS: PERMIT NO
03100037
Alk
NAME:
C� ♦ PERMITLS9UEDATB
'ITA TAJVAR
PHONE: 03
SANITARY N0. CONTROL 10.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3ozp LICENSED CONTRACTOR'S DECLARATION 0
U I hereby affirm that 1 am Eanacd under provisions of Chapter 9(commencing Job Description
with Section 71fkp Df Division 3 ofthe Business and Professions Code,and my license is
in License
Claomd erten' ADD 1834 SQ. FT. /GARAGE F
i License Class Lic.N
E4uJ.go Dam used anpu � ALED
ARCHITECTS DECLARATION -
a UyUy 1 understand my plans shall he used u public rcemdi
S o G Lucnut Profcssmnal NOV / �J
9x m S OWNER-BUILDER DECLARATION j— 2004
2<f 1 masa.Affirm Nal 1 am exempt from Ne Contractors Co Liccnu Lew for the
p O
following mason. em.11(Section](171.5,Business and improve,
demolish,
Code:Any city or county
$ which ro s_.a permit In construe,applicant
improve,demolish,nr mash any timmeu
< prat be is licensed
N eau mquims Nc appticam rnnueh Permit rte a signed Saremem
p�ns
at he is
pursuamm Nc provisions of NC Canlnnur's Liccnu liw(Chxper 9 Sq. Ft. Floor Area
t form meneing wi th Section 7")of Division 3 of the Business and Professions Coet)or
e 5$ Nat he is eumPt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit Subjects Ne Applicant o a civil penalty of 3-a m�irk G,o o
not mom Nan fora hundred doll.ss(S500). AP f`11 Occupancy Type
❑1,As owner of rhe property,or my emplayces with wegas As their able ebmpenssdon.
will do the work,and Ne Imiture is net intended or offered for sale(Scc.7W,Business
and Proessions Code:The Commula"a License Law does not apply to an owner or Required Inspections
property who builds or impmves Ncmon,and who does.ueh work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,Ne building or improvement is sold within one year of completion.the mi
builder will have the burden of proving Nut he did not build or improve for purpose of
sale.).
d1,a net of the p.,my.am exclusively convecting with Iicansed contractors to
construct the pettiest fSec.7044.Business and Profusions Cade:)The Comncwh Li
cards Law dors not apply to an owner of property who builds or improves thereon,and
who contracts for such pmjects with a conn elor(s)licensed puts...uo the CorraCIM s
License Law.
❑I am exempt under Sec. B k P C for Nis..on
N z4:yrt d _ _
Date 7
WORKER'S COMPENSATION DECLARATION J -
1 omby strum under Penally of perjury one of the following declarations:
❑1 have and will mai main a Certificate of Consent o self insum far Worker's Comped
sation,as provided for by Section 3700 of Ne Labor Gale,for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,an required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or IC55.) -
Cols weirs,need not he completed If the permit is for one hundred dollars(91tla)
1 anify that in the performance of the work for which this permit is issued,I shall nut
employ any Penson in any manner so As lm become subject o the Workeri Compensation
Laws Df Califarnie.Date
Applicant
NOTICE TO APPLICANT:IL afar making this Cenificau of Exemption,you should
become&Object to the Worker's Compensation previsions of the Lebo Code,you must
z forthwith comply with such provisions or this Permit shall be deemed stroked.
Zvy CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is constructor.lending agency for Ne performance of
'Yv Ne work for which this permit Is issued(Sec.3(19],Civ.C.)
YQ Landch Name
5 z Leader's Address
J Q I ramify that 1 have mad Nis application sand Ads e Nat the above information is
i F correct.I agree to comply with all city and county on inancea and sum law$relating m
�U building Construction.and hereby authorise representatives of this City to enter upon the
[Ll ahbvcmcmiunadprepcny fmimpenses which
may
a
4 (We)agree to um,indemnify and keep harmless the City of Cupertino against
in
qunce or the costs and capcnusmit. mayin any way accmc against mid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE 'ULATIONS.
3
gnewre of Applicant/ bmrannr Re-roofs
Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar fDlrm Wilding occupant store or handle hararduudh iai
on
wed by the Cupeninb Municipal Code.Chapter 9.13,and the Health and Safety
'S tion 25532(a)7 �N/ All roofs shall be inspected prior to any roofing material being installed.
ma
1
Will the applicant or future building ottupam uw egaipment or dcvia5 which -If a roof is installed without first obtaining an inspection,I agree to remove
oma ha]2moY5 air contaminants turned by the Bay Area Air Quality Management all new materials for inspection.
Diane,'
❑Yea
I have mad the hummous materials mquimmcna under Chai ar 6.95 of the Califor.
nia Health @ Safety Cale,Sections 25505.25533 and 25534.1 undersand Nat if the building
does not currently haw a tenant,Nat It is my responsibility to oddly the occomot of Ne
requirements which must m met proor to issuance of a COMECam of O:cupanc.
(, . �� Signature of Applicant Date
ownar or atthonaed agent f Date All roof coverings to be Class or better