01060057 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
18671 NEWSOM AVE. 01060057
OWNER'S NAME: APPLICATION SUB DATE
• ROMAN AVILA 06/11/2001
PHONE: SANITARY NO. CONTROL NO.
w O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ELECT UMB - MECH
a
NZw6
C z Ei z LICENSED CONTRACTOR'S DECLARATION Job Descri on
O ln_ I hereby affirm that l am of the B under provisions of nsChapter Code,and
(commencing
pwt_w with fall fore and cfec,.Division the Business and Professions Cade.and mylicens
a Isin cefull(lime and effect.
ai0xU Daaxeemx,s Lie.» REPLACE TILE/SHOWER/WINDOW
ct, Date 5 Contractor
F u.O'r' ARCHITECT'S DECLARATION
Y� 1 undcnand my plans sM1vll be used az public retards
n ina Licensed Professional
OWNER-BUILDER DECLARATION
i,i1 hereby affirm that I am exempt from the Contractor's License law for the
F ZQ, following reason.(Section 70)15,Business and Professions Calc:Any city or county
51
❑ which requires a permit to construct,alter,improve,demolish,or repair any structure
y5r ..prat t ' la wreath pplc' tf ch pm i fl 'g dsate Hent
c. ma he isr en edfamiliars ullhi proor the Contractor's License Law yr'n mm9 S ht F1okr-A ea i 259ALlation
(xa etgwith Sect ]Wu)ofUvis 3oftheBusine- ndPmfvsionsCode) y9 _. ,:'�•, t.i�.S -j(`;o\•
or that he is exempt thcrefrain'and the basis for the alleged uanpuon.Any violation
of Section 4031.5 by any applicant for a permit subjects the appl imam to a civil Penally
.or not mDre than love handled donan(s500). 375fgRJ�416mtGo ':. Occupancy Type
01,as owner of the property,or my employees with wages as their,sole compensation, 1
will do the work.-and the structure is not intended or offered for sale(Sec.7044:
Business and Professions Cale:The Contractor's License Law does not apply to an 516 — FINAL B{ga40rgfp(gspections
owner of property,Who builds or improves thereon,and who does such work himself d
or,h for
n'. 6Iaemployees.p den that suchimprovementsnotintendedpia,
or
.c n df 1 If,how- th building Pro , s id idi o Year of
'cot improve
Ih b 'W r 'ilk theburden fp 'ng that hdid build or
for p ryo or.-hi ,
01,azowner n ameelIncreased
y elusively contracting with o 1 tors,o
cunsm c protect ]BU B . e.xs ess ons C I )Th C t aor's / 1
Lidocs pply t of property a build, p ,h ran /
8 /
who cont f of a conn orfs)I d pursuant to the -.._—
Con ten a ,wsm r s witnO
mpt sea rSec B&P C forthis mason s" ti.•:L '4nf:rs /
_ 'ow r ate' bhl•���Q/
WO I ER'S COMPENSATIbbbNNN DECLARATION
; • IM1ercby affirm under Penalty or perjury one of toe.following dalamlionto
❑ 1 have and will maintain a Certilicam of Consem',o scllinsure for Worker's
_ Campensatinn, as provided for by Section 37W of the labor Code. for the _
performance or the walk for which this permit is issued,
01 have and will mai main Worker's Compensation Insurance,ah required by Section
37M of the Labor Code,for the performance of the walk for which this permit is
- nation In..mice camel and Policy number are:
' issued.My WorkeCs Compe y
Cariier• .:) L'r.". :• Policy Nu.: -ftp I
t• f:7t', z�'`!"#.t t,!^- t_I `Z_L:
n (CERTIFICATION OFEXEMPTION FROM WORKERS-i% •' 4
COMPENSATION INSURANCE
. I .... -.._.__-___. _._ ..... .-_.. ._._.....
t (This sccuon Had Hol be eompined if the Permit is for orte hundred dollars
(SIW)or less.) ,
,` 1 ri fY,halm,h cein f ort fur whet e t s ied,1
hall no,employ any Person m any mannerr m sea to become
u bj nct ss to the Workers' -
Comion laws of Califpmia.Da
icilat le
"
NOricETO APPLICANT:If,afar making This Cenif,.1"FExemplion,you'should
bccomc zuhja,m the Workers Csimam
pxmion pvlsions of the Luhor Cdda,you mu.a
Q 0 forthwith comply with such provisions or,his permi,shall be deemed m,idarJ.
Eoil, 's - %CONSTRUCTION LENDING AGENCY - -_ - -
:71 hereby vffrm that Ihcre s d ronstnci ori lenti ng ngensy far the perfdmmove
oaf'he k to which do pe it :issued(S 3097,Civ.C)
L,Q 'Led Nm ' - .. . . .. ....... . __. _ .-_...__ .._ .... _ -.—....... .. . ... ._
_.Z Lenders AddressJ . '.j• ,t)l
V.0 { 1 certify that I have read this appl kation and sate that the above information is
kx'E. re cel.1 agree to,comply with all city and county ordinances and state laws relating
C U to buildin,<nnxwction.and hereby autAorii'e'ieprtsematives of this city to enter upon
y W he tinned properly(or,inspeci s s. _ ..
(W' agreemmvc,indemnif me,1mmdcx,mr Clty of Cupertino against
L- liablli- judgmen axis send emea which,may- eny way uccna against snit
7- n mane oft gr ing'of this permit.
LICA:' UNDERS s' SANDWILLCO P N'ITH�}L`NONPOLYT Issued b Date (O
tg pplicr a/Cx ntivaor:, lG • .D� Re-roofs
Will the lure buildin a
' _ ALS,DISCLOSURE
lIAZARDOUE MATER(
e Cupertino
no g e paint 1 .and t n ealloas maee4l Type of Roof - .. .... ._. ..._._ ..__ . _ ..._.
az defined by the Cuperl ht c p tCal Chapter9.1 ,and the HwIM and Safety
Cod sen on 2353_O . ;', i ., + - 5 .. -[, ' 1 !• J.,.
❑Y x• oNa t. :.'v +'a All.roofs shall,be inspected.prior.to.any roofingmaterial being-installed........ .- ..
�J1itheapplicantorfuturebuildingoccupantuseequipmentordeviaxwhich If a roof is installed without first obtaining an inspection;'( agree to remove
emit nazallom ter contaminants az refined by the Bay Arca Air Quality M1lamgetttem,
District? - . . all new materials for inspection._Applicant underst_ands•__and will comply with .-
0 vex- 0 Nrvo. all non-point source regulations.,
Ise, .
-ad lske ta:aNws materials requirements under chapter 6.95 of the
..in H� ,n&Sure,,C VTi25505.25533 and 35534.1 understand Nut. -
--_-
ifthehim gdue s hm cu- yh.me a,nu that iris my re"nsibi It,,iontSti y the l
,of t slut t Is uhimh tnu, e tel prior to issuance of a Cailficate a-
ocy
Signature of Applicant - ._ _ - _ _ Date .
Grief All roof coverings to be Class `B" or better
OFFICE. . _. . . . . ._ ..