04100045 CITY OF CUPERTINO ,�
BUILDING DIVISION PERMIT . CONTRACTOR�INFORMATION
BUILDING ADDRESS: "'"""04100045
ERMIT ND
t 04100045
121391 ('QT.lTMRlTq AV
OWNER'S NAME: PERM117MUEDATE
PATRICIA GREEL
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION O O O O
a U I TO affirm Nn I am lianse4 under provisions of Chapter 9(commencing Job DCSCrIp1)9j1 B���
with Smile.Ihexa y affirm
thatio a offt camood peas W visionsiof haptenCooke, 9 my(commencing
cense u Iiia u
in full force and c e
;�_ tion aag1 Id Les Zr S REPLACE ELECT. SERVICE
c Dam. �� ELER
entocone. CONTRACTOR: BILDZ
ARCHDECfS DEC LA AT N OCT
I understand my plans shall he used as public rumen e1001.
cgu L 4
3 a.G G Licensed Professional
3 OWNER-BUILDER DECLARATION O rs rs ®� as
.�<X 1 hereby affirm that I am exempt from the Contractor's License Law for the SUMNG
I\CC�^`k
um
2° which
following moon.(Season construct.
Business and Professionscli Code:Any city or coumy
K m� which its usu•permit so ennnmca aim.,improve.demolish,or e pair ed awment
'tzy primpiuiensedprsuantto ftreat thovisioso forsuch Contrarmiupicense aw(Cha mem
< Boas he is licensed pursuant the provision of the Contractor's License law(Chapmr9 Sq.Ft. Floor Area ValuaNf3f1800
��$ (commencing with Satinn7M)or Division 3 of the Busitmssand Pmfusimu Cook)or 7r'
_
that he is exempt dworfrom and the hub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number Oe
not mom than EK hundred dollars(sten). Occupancy Y TYP
❑I,uawncr of the proprny,mmy employcu wish wagnu thcv role campensnlpn, 36204007 .00
will da tip work.and the swctum is wt intended or.ffa W forsale(Sec.7014,Business
and Pmfessiou code:The Congacmr's License law docs out apply in an net of Required Inspections
prepany who builds orimprovna thereon,and who doessuch work himself or through his
own employcu,provided that such imprommemu arc not intended or offered formic.If.
Wommq me building or improvement is sold within one year of compleuon,the owner.
builder will ban the burden of proving thm he did not Guild or impmve for purpose of
tile.).
El 1,as owner of the propeny,am exclusively contracting with licensed contractors to
consumes the project(Sec.7W.nosiness and Professions Cade:)The Comtnctoi s U.
cense law docs not apply to an owner of propcny who builds or improves Hereon,and.
who contracts for such projects with a eontrocions)licensed pursuant o the Contractor's
License law.
O l am exempt under Sec ,B&PC for this reason
Ownu Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of she following de bunion:
1 ham and will maintain a Certificate of Consent o self-insum for Worker's Compete
cation,as provided for by Section 3700 of the labor Code,for the perfprmame of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as"aired by Section
3 00 of the labor Code.for Ne performance of the woh for which this permit is issued.
My VimuCc--h--C��om,rinumn Inst n¢carrier and Policy number are;
Cartier. l/• t_ Policy No.:. '7'7 S53�'V
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secure need not Wcompleted if the Permit is for one hundred dollars(Slip)
lass.)
I cctuW that in the performance of de work for which this permit b issued.I shall not
employ any person in any manner ed as or become subject o dp Workers Compensation
Laws of California.Do¢
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
become subject to the Workeh Compensation pmvislons of the labor Code,you most
.0 Z foMwiBi comply with such provisions in this permit shall be deemed ronkcd.
ZO CONSTRUCTION LENDINGAGENCY
I hereby affirm that there is a construction lending agency for etc performance of
G' the work for which this permit is issued(Sec.3097.Cie C.)
Isnder's Name
z Lcndcls Address
U O I anify Boas I ban read this application and sum that the ebon information is
Fcorrect.1 agree to comply with all city and county ordinaneu and state laws relating to
pU building construction,and hereby authorise reprcsenuums of this city to enter upon lic
W above-mentioned property for inspection purposes.
(We)¢gra p son,indemnify and kap hormleas the City of Cupertino against
H liabilidcs.judgmenu,casts and expenses which may in any way aaroo against said City
U Z in eomequenec of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLON-POINT Issued by: Dat
*/
SOUR�$�AT10NS.p /p J
"��+— INS Re-roofs
Signature of App canVConua to, Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the..pliant or future building oecupansaso a ar handle haurdous material
Issuer d by the Cupertino Municipal Codd,Chapter 9.13,and Bic Health and Safety
Calc,Section 35533(¢)?
U Ycs '0 NO All roofs shall be inspected prior to any roofing material being installed.
Will Ne applicant or rums building occupant use aquipment or dcvian which If a roof is installed without first obtaining an inspection,I agree to remove
mit hvardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? / /
❑rs @7r
I have real the h=Mmsmamrials mquimmcnu under Chapter 6.95 of the Califon
nu Health&Safety Cetao Secuons35505.25533and2553a.Iumereard thnifdp Wilding
does Out cmandmom Nat it b my responsibility an notify rite occupant of the
rcqui Nhmn be merprinrm panapncdnifiamprQaane Signature of Applicant Date
/� °LP
All roof coverings to be Class"B"or better
Owns or mulmnc gent ba.