04080087 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT � CONTRACTORINFORMATION
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BUIL DING ADDRESS: PERMIT NO.
04080087
PANDIRY DR
E
RS NAME: PERMIT nUE DATE
E: SANITARY OL NO.
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION Job DeS O
F I hereby affirm Nal 1 am licensed under provisions of Chapter 9(commencing
�am with Section7(idl Division Softhc Business and Nuessium Code,and my license is
inmumresandeffect. DEMO INTER. WALLS/TSAR
j�Z License Class Lic.M
°ax ARCHITECTS AUG 1'1 2004
ARCHITECTS DECLARATION
y < 1 underaund my plana shall be used as public records
Oto pp
u0 Licensed Professional ry Q ®�
OWNER-BUILDER DECLARATION II�NI
<E 1 hereby affirm that 1 am exempt from the Contractor's Liccnx Law far the
p0 following match(Section 7031.5,Business and Professions Cods:Any city or County
%m which requires a permit to cnnstmct,aluq improve,demolish,or repair any mructum
m�'^ prior in its issuance,also mquircs be applicant for such permit to file aligned statement
='< Nat he is licensed pursuant to the provisions of NC Contractor's licenseLaw(Chapter 9 Sq. Ft. Floor Area Valua[on
zra (commencing with Section 71)0())of Division 3 oftbe Business and Prafcamosu Conic)or
C.e3 that he is exempt therefrom and be basis for be alleged exemption.Any violation of
Section 7031.5 by any applicant for a p.it subjCCU the applicant to a civil penalty of 3 2WN ViU0*gr0 0 Occupancy Type
not mom Nan five hundred dollars(S500). r ,
I,ss owner of the pmpeny,m in,employees with wags as their.mlc compensation.
will do be wm@ and Ne struotum is not intended or offered for sale(See.7060,Business
and Pmreaioru Code:The Convamo's License Law it.nut apply m an owner of Required Inspections
pmpeny who builds ow
m impra thereon,and who does such work himwvor Nmugh his -
own cmployees,provided Nat such improvements arc not intended.,offered for sale It.
however,the building or improvement is sold within one year of Completion,be owner-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sa1c),
0 I.as owmr of the property,am exclusively contracting with licensed CoOwemrs N
comtmet be project(Sec.701 Business and Professions Cade:)The Curdua mrs Li-
cense Law docs not apply to an Owner of property who Wilds or improves themen,and.
who convacu(or such pmjccu wiNaconvxtcou" ermscd a ant to Nc Conuutafs
License Uw. '
I an exempt mul Sea` ,BA,PC for thi rc a
YJ IORXB MPEN ATION DEC ION
rcby aRum under y of perjury one of be following declarations:
1 have and will maintain a Cenificaln of Coment to self-insure for Wurksr's Compcm
asaxion,u provided for by Section 3700 of the Labor Cade.for be performance of the
work for which Nis permit is issued.
❑1 nave roti will maintain Worker's Compensation Insurance,as required by section
3700 of the Labor Cade,for the,performance of the work for which this permit u United.
My Workers Compensation Insonne,artier and Policy number are:
C.mC,.. Polity N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhisxclmo need not bemmplewd if to permit is fmonc hundecd dollars(SI(MI)
nr Ica.)
1 certify that in be peromtance of the work for which this permit is issued.1 shall not
employ any pawn in any moms,x as m become subject to the WorterY Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT.If,after making this ccnificate or Exemption,you should
become subject o the Worker's Compenutlpn provisions or be Labor Code,you must
J O forthwith comply with such provisions or Nis permit shall be deemed revoked.
z 7) CONSTRUCTION LENDING AGENCY
u
,g+ k for which
that them isimit(Sect3097,leading agency l'pr be Performance of
!Yi > the work for whish mix permit is inmd(Sec.3097.civ.C.)
R3 Uns Name
:) zQ. Lende&r'r's Address
U 0 1 certify that I haw rad this application and suss that the ainw,information is
Iy F coney I agree m comply wit all city and county oNiromeas and smile laws relating or
0U building construction.and hereby audimm,representatives of mit city to enter upon tW
almve-me Ju touch.cmi for inspecuonpurlpses
H CL (W o aw,indemnify and keep harmlm me City of Cupertino against
N liabili' s,judgmcnn, osis and expcp¢a which may in any wayJGmc against said City
U z inc msequcnce of the
^' A LICANT U OE OS N CLL OMPLY WI ALL O OI Issued by: Date
r'A %Da
pW1e ` Re-roofs
RDQU MATERIALS DISCLOSURE °a Type of Roof
Will the apphe orfumm building ceeupentstme m handle havardmos matmial
u defined by the Cupertino Municipal Code.Chapter 9.13,and be Health and Safety
.s Yet Vcs zss33(a)? x o All roofs shall be inspected prior to any roofing material being installed.
A N
Will the applicant Or future building Occupant use equipment m device which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardnus air coamminanta as armed by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes 9N
I have rcad0 InUoucrial$rcquum5=nn derChapmf6.95ofdteCalifpr-
niaHeaW&mare Codc, ons35 5533 and dthm irthe Wilding
doenot c ndy haw a te n t it is p risibility m nu'y the eccupant or Ne
require nBw r et ret ttnracen;rotepraetrpan igna[ureofApplicant Dale
Owner bond a em `' D,te/ All roof coverings to be Class "B" or better