04090243 CITY OF CUPEW11NO - <+ °^*x'*L
BUILDING DIVISION PERMIT CONTRACTORINI ORMATION
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BUILDING ADDRESS: SAMUEL CONSTRUCTION 1111 ND04090243
?74417 rTTDPPTTNO RD
=R'S NAME: PERMITLSUEDATE
SUNNY VIE MANOR -A497 PT.nWT,11TqTA AITF, /22/20114
PHONE:
SANITARY N CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOp LICENSED CONTRACT'OR'S DECLARATION
e P let.
lip by affirm Nat 1 am liasacd under pm unto of Chapter 9(commencing Job Description
�Zw with$qe( 11I. 11ivia.11 LNC Business 0ofessions Code,and mylicevc is
loco reeaode m' S44�7 Z UPGRADE BATHROOM (NURSERY)
j n i License Class Lie.g
z_� Dam Conlncmr_ rsG
ARCHITECTSDEC ON
Ise rsand my,tarts¢hpIlk Jas res ice.
Ddu SeL✓s•LxR.L Lens
C H cm
Luc,sed Professional
g OWNER-BUILDER DECLARATION
<� I hereby aRrm Nal 1 am exempt from the Cansrenofs License Law far the
D O following mason. Scctiun 7031.5,Business and Profcssium Code:Any oily ar county
m which reyuims a permit m emmmmL alse,,improve,demolish,or term,any ssrvclure
prior In its issuance,also requires the applicant for such Dermis to file.signed malcontent
< Imtkimmm�scdrursaacomms,rovimmrmnethocamra:Rir,u�<Ipei.w(cn.rlc,, Sq:Ft.F.loorArea
Valuatwn - . . .
(mmmcncingwithS tiont000)ofDivision3n(tk B6sioessand Profrssinm CM).r (r —',1 ��•'s II-'—��'
i $
that k is exempt therefrom and Inc basis for the alleged cacmptlon.Any violation of l( 1 P 1
Section 7031.5 by any applicant for a pcnnitsubjeeccru the applicant he a civil penalty of It_l!) t3�.a-nnt1N� Q�o Occupancy Type
not roam than Rte hundred dollus(53(10). I r / I( / LImJDt1
1 I�--J
❑1,as owner or Ne property,or my employees with wages as diel,sale compensation, ) 1� •� �� (I
will do lk work and the sentence is not inendedara@red raised. 1044,Businrst " tL_ f t
and Profrsdomu Cade:The Conuulors Liicnti Gad_orti not Ipply iota.owner o [,� Required Inspections
property who builds orimproves dierean,and who does suchwork himultf''or through his
own employees,pmvidod thatauch improvements am not intended aranered forann If,
however.Ne building or improvement is sold within one year of completion.Ne owecr-
builder will have the burden of proving that he did not build of improve for purpose of
sale.).
0 1,as owner of Ne property,am exclusively contracting with licensed contractors to
construct the project(Sec.TI)q Business and Professions Code:)The Contractor's Li.
mase law dors not apply to an owner of property who builds or improves Ihe¢an,and
who contracts for such projects with.mmracmr(s)licensed puts uanuo the Comreelm"
Lieenz law.
0 l am exempt under Sec. ,B&P C for this moon
Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm not penaby of perjury..of to fallowing daelantim s:
0 1 have and will maintain a Cenifieamof Certain to self-insure for Workers Compcn- _
cation,.Provided for by Scotian 3700.1 the Labe,Cade,for in.penorrnance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,ns myuimd by Section
37M of the Labor Code,for Ne penornomec of the work for which this pa,mil is issued.
My Warker¢Cnmrenmuonlnsunoceearn audix.ficytioninkrare:
C LGoy�fs oFLoncYa yNo.: YO IY3
CERTIFICATE OF EXEM NFROM WORKERS'
COMPENSA INSURANCE t
(Thu semion need not rte comDle irtk lcrmit is foronc hundred dollars(SIM)
or less.)
1 certify that in the perhmnanec of Ne work for which this permit is issucd,)shall nus
employ any person in any manna sa in in kcomc subject to one Workeri Componsation
Lova of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cxmficam of Exemption,you should
become subject he the Workers Copmenco ion previsions of thc labor Code,you must
.,,Z foMwi to comply with such provisions or Nis permilmhall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(r I hemhyafBrm don tkre uta conmmclinr lendinpageney In,Ik renmmance of
CG Ne work for which this permit is issued(Sec.3091.Civ.C.)
t>)Q I-cerm'.s Namc
L<nd
z c,'x Address
U O 1 minty that 1 have mad this application and sunt that the shove in(..limn is
kLF-' correct.1 agree to comply with all city and county ordinances and main laws miming to
O V building construction.and hereby anthorirz representatives of this city to enter upon Inc
W alove-mentioned proreny for inspection purposes.
(Wo)agree to save,indemnify and keep M1umicss the City of Cupertino against
Fh liabilities.judgments,can.and can.which may in any way.roue aguomland City
V Z In conxepucncc of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date !/
SOURCE R�E[GUULLATIIONS.
.� �c. ^ 2
S2 ofApfriiucxpaac Data Re-roofs
HAZARDOUS-MA'11RIALS DISCLOSURE Type of Roof
Will Ik applicant or future building occupant store or handle hatsolaus mention
Vdefined by the Caperton Municipal Cade.Chapter 9.13,and the Health and Safety
'<.0YeC525532(a)? J��ssN\a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or al lube builJing xmpant tame cyuipment or dcvirss whicM1 If a roof is installed without first obtaining an inspection,I agree to remove
emit harardoum air conmonams as defined by he Bay Area Air Quality Management all new materials for inspection.
District? -
DYcs MNo
1 have mil the haxam.m.materials rtquirtmcnu undcl Cha ne,6.95 of the ethics.
ria Health&SnelyCode,Sections 25515,15533 and2 534.1 understand thatifthc Wilding
deem not cuncmly have It ananL diel it is my responsibility to notity Ik amara'of the
requirernen M1ichmum beme,prionuissuaracofaCcnifmaa 2�a Signature of Applicant Date
owne,pratimari S Date All roof coverings to be Class"B" or better