04050116 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT ,CON RACdTt�R INFORMATION ,
BUILDING ADDRESS: RON PARIS CONSTRUCTION CO ENCTNo04050116
OWNER'S NAME: PERMIT MUE DATE
E: SANITARY qg*OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
m 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description I p AL E
with Section]0D)of Division 3 of he Business d Professions Code.and my license is �'pe7p
imm�rn deffect. y59 NEW POOL & TI
D Z Licenses Lie.//
'Fp Dmh CuntrazWr
ty k ARCHITIS"IE TION JAN w- 2005
1 undersand my plans shall be used v pubhc records
Pu _
3LLG Licensed Professional
a.ps
OWNER-BUILDER
exempt
DECLARATION ® �I�®Ip �f
nC I naso affirm that 11. cztmpt Imre Nc Contractors e:My City
Law for the 1■I@6�nr
00 following reason.(Section]on LS,Bninusand w,de un Code:Mycity structure I
which acquires a permit to construct,alter,improve,demolish,or repair any stmnure
i- prior in its issuance,also requires the applicant for such Permit o Ale a signed statement
< that the is licensed p..an,to the provision of the Conuacsoh teens Law(Chapter 9 Sq.Ft. Floor Area Valuation
he (cam mencing with Section?0110)of Division 3 of the Business and Professimu Code)or
i
Out M is exempt therefrom and Nc basis fm the alleged ezemptim.Any violation of
Section 7031.5 by any applicat to,a perrmit subjeca 0e applicant l0 a civil penalty ne T of APN Number Oeeu ae
bre memo 0.RK hundred della.($500). P Y YP
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and But structure H not intended or offered for able(Sce.]OC4,Business 33102 . 00
and Professions Code:The Commandoes License Law docs amt apply to an owner or Required Inspections
property who builds o!improves dtereon.and who does such .,it himself or borough his
own employees.provided Out such improvements are not immnded or offered for male.IL
howevc,be building or improvement is sold within one year of completion.Ne Owner
Witter will have the burden Of proving that he did oat Wild ror improve for purpo m of
sale.).
1 u Owner of the property,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7(]04,Business and Prefeseiom Cade:)The Concourses U.
chats Law docs not apply he an own!Of property who Wilds Or impmws Ncrtan,and.
who contracts far such projects wild a contmemr(s)licensed pursuant to Ne Contractors
License law.
of ezem der Sc ,B da P C far Or...an
`
er
ORKER' O PENSATION DE[ RADate _,
TION
1 hereby BSbar penalty or perjury ane of\`following declarations:
have and will mainain aCwfiute of Cotucm to elf-insure fur Workm's Compcm
...non,as provided for by Section 3700 of the Labor Cars,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Codc,ror die Performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7hasection need not W completed if the permit is foram hundred dollars($101)
or lust)
I artily that in the performance of dte work for which Nis Permit is issued,1 Nall not
employ any person in any manner so as to become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of acmption,you should
become subject to Bic worker's Compensation provision Of the Labor Code,you mum
.J Z forthwith comply with such provisions Or Nis Permit shall an deemed revoked.
z O CONSTRUCTION LENDING AGENCY
F Ithereby.1rom 0at mere its conwctinn lendingagenry far Bit ptrfurmmceuf
a 1 the work fur which Nis permit is incest(Sec.IDB➢,Civ.C.)
C A LendtrS Name -
7 z Leadersaddress
V C 1 certify that I haw read Biis application and sate that Use above information is -
LL, H colones I agree to comply with all city and county animates and some laws relating to
�O building combustion,and hereby audtarim represenlnivu of this city m enter club the
W ahOvace.pundreh.c. for
-it c. etion pluck a
gy s.
(We)agree 10 sa c.indemnify ad keep harmless the City of Culmina against
H.Offly inc.mcs.judg of the I sts adcx which may in my wayaccmc againtmaid City
U z in consequence Of Nc gra 'ng car rspermit.
APPLIC UNDE ND AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR UL S.
( r Re-roofs
Si no orApplicanucbrismanor te
HAZARDOUS MATERIALS DISCLOSURE'-- Type of Roof
Will
On applicant or future building occupant score or handle ha arduus material
u derided by Ne CupeninO Municipal Code.Chapter 9.12.and the Health ad Safety
Cwk, 0Yes 25512(0)? _,ra All roofs shall be inspected prior to any roofing material being installed.
❑Yes YI No
Will the applicant or(fuwrc building occas ant ase,e If a roof is installed without first obtainingan inspection,I agree to remove
p equipment Or devices which P
t haiardbus air contaminants u defined by the Bay Arca Air Quality Maagcencnt all new materials for inspection.
uic4 ^
❑Yes
I have mal Ne"oh materials recommend under Chapter 6.95 of she Calif.,
Iia Real SafctycM5()5'25533kmd2553,LlmvdkaRrdm.ifd Wilding
Oedy t it' y respon mo I m mor the occmpmt of Bicnaw jr Issua¢practnhcate cb;a y Signature of Applicant Date
owner
araW�i iac�a,c �� Date All roof coverings to be Class "B"or better