07100110 CITY OF CUPERTINO > `' ° ° "
BUILDING DIVISION PERMIT ���`��i�T�� �������T���� '
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BUILDING ADDRESS: PERMIT NO.
10734 S STELLING RD S I S CONSTRUCTION INC 07100110 •
OWNER'S NAME: PERMITLSSUEDp`TE
RODRIGUEZ APOLONIO AND LOUISA 1868 STONE AVE
PHONE: SANITpRY NO. CONTROL NO.
(408)293-1285
HI'IECTJENGINEER: BUILDING PERMIT INEO
HLDG El.ECT PLUMH MECH
� 0 0 0
i p p LICENSED CONTRACTOR'S DECLARATION JOU DeSCiIpLIOT!
: v� ( hereby afGnn that I am Iiccnscd undcr provisions oC Chaptcr 9(commencing
: z� wiih Scction 7000) of Division 3 of thc Business and ProCcssions Codc a�a�uc�� u F I RE RE PA I R PARTL ROO F RE PLCP/II�TT � NEW DRYWALL
�� y in fuil force and e � � �
�� z l.icensc Lic. N NEW
��° � ARCH[TEGTSDECLARATION ELCTRCL. NEUV HVC & FURNACE & PLUMBING FIXTURES.
i� a 1 undcrswnJ my plans shall Ac uscd u public rccords
)aU
' u- y Licenscd Pn�fcssional
� y � OW NER-BUILDER DECLARATION
� a� I Mcrcby atTirm tha� 1 am ezcmp� from �hc Convactor's Liccnsc Law far the
p O [ollowing rcason. (Scction 7031.5, Busincss and Profc.esions Ca1c: Any ciry or county
�°„ � which requires a permit ro cnnswc4 altcr, improve, dcmolish, ar repair any structurc
° Z y prior ui i�s issuancc. alsu ccquircs ihe applicant for such permi� to file a signcd su�ement
�= 0 ihat hc is liccnscd pursuant to thc provisions o[ thc Conuacu�r's Licensc Law (Chaptcr 9 ;>q. Ft. Floor Area Valuation
u t - �(commenring wiih Scction 7000) of Division 3 of Ihc Busincssand Profcssions Cadc) or $ 213 7 5 7
L �... that he is exempt Ne�cfrom and Ne basu for the allegcd exemption. Any violation of
Secdon 7031.5 by a�ry applicant (or a pertnit subjecu the applicant to a civil penalty of Number Oeeupaney Type
not more ihan five hundred dollars (SS00). 3 9 2 2 � � 5��
❑ I, as owner of Uie property, or my employees with wages u the'v solc compensatlon,
wiIl do thc work and �he structu�e is notintendcd or offend forsalc (Sec. 7044. Business Re uired Ins eCtlOiiS
and Professions Cade: The Conuactor's License Law docs iwt apply w an owner of Q P
property who builds or improves thereon, and wM does such wart himselCor tAmugh his
own employces, provided that such improvemen�s are not in�ended or o(tered for sala If,
hawever. �he building or improvement is sold within one year of completion, �6e ownu-
builder will have �he burden o[ proving ihat hc did not build or improvc tor purpose af
sakJ.
❑ I, as awner of the property, am uclusively convacting wi�h licensed cronuactors to
constmct �he project (Sec. 7044. Business and Professians Code:) The Contrxwrs Li-
ccnu Law does aot apply to an owner o( propeny who builds or improves the�eon, and ,
who conuac�s for such projec�s with a conuactor(s) Iicensed pursuan[ to the Contnctors
License Law.
� I am aempt under Sec. . B� P C for ihis resson ,
Owner Date
WORKER'S COMPENSA'i'ION DECLARATION - � . -
1 hereby �rm under penalty of pc�jury nnc af �he following declantions:
❑ I twoe and will maintain a CeniCcatc of Canscnt to selt-imure [w Workers Compen-
�Gost. u providcd for by Sectian 3700 of the Labor Code, for �he performancc at Ure
rk for whicd this pertnit is iscucd.
�J ! havc and will maintain Workcfs Compensation Insurance, u required by Scction
3700 oC �he Labor Code, Cor the per(ormanee of the woric (or w6ich ihis pem�it is issued. �
My Work s o pe ation 1 unnce nrrier and Policy n ve:
Cartier. Policy No.: /���y���
CERTIF[CA OP EXEMP'I'[ON FROM WORKERS'
COMPENSATlON INSURANCE
(This secUon necd not be completed if the pertnit is for onc hundred dallus (E I00)
or Icss) •
I cenify th.t in �hc perfortnancc of thc work [or which ihis permit is issucd. I shall not
employ any person in any manner so as to become wbject w ihe Workers' Compensatlon
Laws of Califomia. Datc
Applican�
NOTICE TO APPLICAM: If, aftcr making ihis Ccrti�ca�c of Excmp6on, you shoulJ
become subject to �e Worker's Compensation provisions af �he Labor Code, you must
� O forthwit6 comply with such provisions or this pecmit shall bc dcemcd revoked.
z '"' CONSfRUCT10N LENDING AGENCY
Fr r�—� i hercAy a�rm �hat thcre is a conswcdon Icnding agcncy Car thc perfortnarec u(
p! � �he wrork Cur which this permit is issued (Scc. 3097, Civ. CJ
W� Q Lendcr's Namc •
� z Lcnder's Address
V � I cenifY U�at 1 havc rcad Wis application and s�ate that �he above infortnatiun is
w�'" cortcct. 1 agrce io comply with all city and county orJinances and sute laws relaung to
� U building conswction, and he�cby authori�e reprcsentativcs of this ciry to cntcr u{mn tbc
� W abovc-mcntioncd property (or inspccuon purposes.
a (Wc) agme to save, indcmnify and kecp harmless the City of Cupenino against
�,E'�'„� � liabiliuu, judgmcnLC, costs and expenses which may in any way accnu agtinst said City > '^�
V,'� in wnsequc c of �c granti g af this permit. DaLe C� � d�� 1
F-+ APPLI UNDER NDS AND COMPLY WITH ALL NON-POINT Issued by: 1 l
SOUR GULA N. �
� Re-roofs ��
Signa� of Applican�Conuactor ue
HAZARDOUS MATERIALSDISCLOSURE Type of Rc�of
Will thc applicant or futurc buitding occu t storc or handlc harardous ma�crial
ma
as dcfined by the Cupenino Municipal . aptcr 9.12, and the Hplth and Safcty
c«� Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ vcs o
wlI �hc applicant or futurc buildin upant use cyuipmcnt or Jcviar which If a roof is installed without first obtaining an inspection, I agree to remove -
cmit ha•rardous air contaminanls az dcfi by �he Bay Arca Air Quality Managcmcni all new m�.terials for inspec�ion.
��S�;�a
❑ ves o
1 havc mad Uu ha�ardous maicrials requircmen�s undcrChaptcr 6.95 o(U�c Calitor-
nia Hcal�h & cty Codc, Sc uons 25505, 25533 and 25534. I walcrs�and �hat iCtlie building
Socs n ntly havc an4 �at it is my rcsponsibil' y to notify thc occupant af Ne
rzyui hichm me�prio cnifica�co - Signature��fApplicant Date
owncrorauthorizcdagcni p, All roof coverings to be Class ° B" or better