04060140 CITY OF CUPERTINO '*sxfl'° "'�� z" t
BUILDING DIVISION PERMIT "CONTRACTORaINFORMATION
BUILDING ADDRESS: PERMIT N00 4 0 6 0 14 0
10180 N BLANEY AV
OWNER'S NAME: PERMIT LgUEDATE
MICHAEL GARVALE 06/16/2004
E: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 l� (� (�
iO' LICENSED COMAACTOWSDECLARATION JbDescription
uF I hereby affirm Nn I an licensed a Provision of Chaper 9(commencing o
Zwith 'on ")of Division3ofUe Busrt dP fccsion Code. dmylimmucis a LE®
:A=n in mBm derfeea-Q - WINDOW REPLACEMENT/ .2 BATHRM�
Z;: I ONTRACTOR: LEAHY CONSTRUCTI N
—p Da¢ Comrxlnr
ARCHITECT'S DECLiggialON
U -I un rsund my plans shat he used as public rtcnnis
DEC �j 2004
30,� Licensed I'mRsam sl
3 OWNER-BUILDER DECLARATION
< I hcrchy aRrm Nat 1 am exempt from the Commehirs License Law for the B (j
p2 following reason.(section7W1.5,Business and Profession Cade:Any city or county p■C++pp'
which regmiru a permit to consumer,alar,improve,demolish.or repair any structure
FIs ILMN
prior Or its issuance.also require the applicant for such Permit o File a signed saumem
Hro Net he is licensed foomem w the provisions of rhe Contractors Limns,Law(Chapter 9 Sq.Ft.Floor Area Val ldZm00
(cammcncing with Scnion7W0)nf Division of the Buzirussand Profession,;Coco)ur
a. that h is exempt thrtfmm and the buss for the alleged exemption.My violation of
Section 7031.5 by say applicant for a permit subjects the.,It.,It.,w a civil penalty of APN Number Occupancy e
.or more than me hundred deltars(ssno), 31631024 . 00 P Y P
❑I.uowner of Ne PmlxnY•mmY employee with wagexu thehsule compcnsstion, -
will do the work,and the structure is not intended or offered fomite(Sec.70W,Business
and Professions Code:The Contruwri n License Law donot apply w n owner or Required Inspections
property who W ods m i mpmvex Uteseon,and who doss such work hime al f or through his
own employ..provided donsuch improvements art not intended.,offered(.rule.IL
however.live building or improvement is sold within one year of completion,the Owner.
builder will have the burden of proving Nat he did Out build or improve for purpose of
sale.).
❑1.as owner of the property.an exclusively contracting with licensed cunuacwrs in
construct the pmjem(Sec.7054.Business and Professor Code:)The Contracu,'s Li-
come law does not apply to an owner of property who builds or improve demon,and.
who contracts for such projects with aconmetogs)licensed pursuant in the Conuaeto's
Lmm"'Law.
I am exempt under Seo .B h P C for this..on
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury arc of the following declaration:
have and will maintain a Ccnifieuu of Consent to self-insure for Worker'sCompen-
.hen,u provided for by section 37M of the labor Code,for the perfomtance or the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Imran¢,u reputed by Sccdon
3700 of the labor Code.for the penfonoance,of the work for which this permit is issued. ,
My Workers Compensation Insurance canner and Policy number am:
amu:
CERTIFICATE OF EXEMTn 'ROM WORKERS'
COMPENSATION INSURANCE
CITU section need Out M completed ifft Permit is forone hundrtddollus(SIM)
or les.)
1 ttnify Nat in enett of th work f r which this permit u issued.l shall not
em"0'anyin"Ou" to
loco mcsubjecuo the Wofkera C.mpensauon
laws.(Csf an
Applic net
Nan AP I Nr:If,after making this C oificae of ExcmpUon,you should
bee. - bjec to the Worker's Grope moon pmv ion of the labor Code,you must
,z foMwith complywithsuch Provouonm Nisromil hallMdcemrA naked.
'ZO CONSTRUCTION LENDING AGENCY
(-+ I hereby affirm that them is a eonsumetion lending agency for the performance of
6i > the wort for which this Permit is issued(Sec.3097,Civ.C.)
dA Lenders Name,
7 z lenders Address
U Q 1 ceNfy Net 1 have read this application and mule that the shove information is -
IL P Cancel.1 agree to comply with all city and county ordinances and sure laws relating to
OU building construction.and hereby&urban=repmxnuives of the city to enter upon thc
W abovebi oilrmdpmpeny for Inspection which may
a
0. (We)agree to use,indemnify and keep harmless the City of Cupertino against
N Ilaa'... 'sed cnts,cuu andexpe"v,which mays y scene againsueiO City
U Z AP" IC "4NDERro" "g StAND W t L C Y ITH ALL N -PO Issued by: Date
S R tRe-roofsi w of Aractor kRDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building omupantsmm or handle huardon meedai
as defined by the Cupertino Municipal Code.Gaper 9.1].and the Hiedus and Safety
.de.Sccdes zss3z(o7 P P Y g g installed.
pYex o All roofs shall be inspected riot to an ,..fins material baso
Will thc applicntor(more building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hanrdoms air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yn Nu
nh. ?yard ism urialsreyui cnu under ChaPer6.95 afthc Glif.rynuHwcard mr 305.2553sderChr6,95tdocs na anon er itis my ife.ihility w..fity the or., rrequiretbCmet 'o wissm ce.f.ccitificae.f .. Signature of Applicant Date
Owner d1arrhiagent All roof coverings to be Class"B"or better