04030029CITY OF CUPERTINO
COR1INFOr RMATION
BUILDING DIVISION PERMIT
ONTRAC
.
BUILDING ADDRESS:
SARATOGA CONSTRUCTION
PERMTTNo.04030029
R'S NAME:
PERMIT ISSUE DATE
10 12
ONE:
ANITARY 0 OL 10.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDGEIFLT PLUMB MH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hemby aniren Nat I am licensed under pmviaiam of Chopter 9 (commencing
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with Sectio 7=))af Division3of Ne Bus wdProfessions Code,andmylicenuis
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in run �ame^[�ae t \ a 7' 726-9-3
License CTau s LJc.
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round my plans shall bee used as public rteoON
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Licensed Pmfeaskmal
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OWNER -BUILDER DECLARATION
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I berchy affirm Net I am exempt from the Contractors License Law for the
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following mason. (Section 7131.5, Business and Profesons Code: Any city or county
which ruquires a permit to consumer, alcor, impose, demolish, or repair any Moselum
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prior tons hont...bu requires uuapplicantfor such Permit to rile a signed statement
UcenscLaw
Sq. Ft. Floor Area
Valu tion
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thmheislicensed pursuant othe provisions ofthe Contractor's (CIOPter9
Q(commencing
with Section 9(flay) or Division 3 of the Busi..M Professions Code) or
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that M is exempt therefrom and the basis for the alleged exemption. Any violation of
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Occupancy Type
Section 1031.5 by any applicant for a pemnit subjects the applicant to a civil penalty of
not mom Nan rim hundred dollars ($5001.
I,uowner oftM popcny,mmy employees with wegesas their sole compewtion.
-
ns Required Inspections
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willdoNework. and Nenmcture ianoanunked crorle,ed forsak(Sec. 7W. Business
and Professions Cade: The Contractors License Isw docs rot apply to an owner of
property who Wildsorimpooms dercon, and who doeaslCh work himulror throughhis
own employers, prodded thaluch imprommens are not intended oroRered formic. It.
hum.. NC Wilding or impromnent is sold within oto Year of completion. the owner -
builder will hese the burden of proving that he did not Wild or improve for purpose of
sale.).
❑ 1, as owner of the property. ,m eaclusumly convecting with licensed conoacom to
,.¢trout the project (Sec. 1060. Business and Pofessims Code) The Conuacteru U
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cense Law does not apply m an owner of property who Wilds or improves Nemon, and
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who contacts Lou such prokes with a crauscon(a) licensed pursuant m lac Contnctura
Lk,nu Law.
❑ I we exemptunder Sec. ,B&P C LOU Nb moon
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WORKER'S COMPENSATION DECLARATION
1 Mosby affirm under austy of perjury one of the following declarations:
❑ 1 have and will maintain aCenificate of Consenuo self-imurc fm WorMM1Compen-
.don, uprovided for by Section 3100 of the ISWI Code, far the peAorm-he- of Ne
work for which this permit is issued.
❑ 1 have and will mdmein Workers Compensation Insmence, u mquined by Scnion
3100 of the L swu Code. Ine the performance of the work, for which this permit is issued.
My Worker' o Pmotion nsunnce came, and Policy number ants:: /�
Policy N 2 c r0� 42 Z
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Ca
ERTIFICATE OF EK 0 OM WORKERS'
COMPENSATION INSURANCE
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(Thu section need nolbecomplcud if ted Permit u (mom hundred dollen ($1011)
Or Less)
I cenify Net in the performance of the work for which this Permit is issued, l shall not
edploy any peon in say manner an as w become subject to the Warkers'Compemauon
Laws or California. Dau
Applicant
NOTICE TO APPLICANT: If. after making his Certificate of Exemption, you NouW
become subject u due Wot,rs Compensation provision of the, Luber Code. you muss
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forthwith comply with such provisions Of this Permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
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1 hereby infirm Nat Neu is a conetnu:tinn lending apeney for the pcHurmantt of
the work for which this permit is issued (Sea 3097, Civ. C.)
ALenders
Name
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Lendere Address
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1 certify Our i hove read this application and sou that she Above informed.. is
correct I agree to comply with all city and county ordinances and sus laws misting m
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building construction,)agreLotand herobysuNond mpoescntmim of Niscity Ne
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above mcntiuned property for inspection Purposes
P.
Coploirupnn
(Wc) agree w cove. indemnify and keep hurreshoul the City against
i y
in an ntCupenst
liabiliues,judgmens.cosu and expewnes which may in any my acerae against mid City
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in ,moss scr cc of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
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SOUS LATIONS.
RE U
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roofs
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HAZARDOUS MATERIALSIDISCLOSURE
Type of Roof
Will tM applicant o future Wilding occupant som or boll, hvardom material
defined by Ne Cupertino Municipal . Chapter 9.11, and Use Health and Safety
e• Sccuon 15531ca)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hmowdom air cottoned. as define by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
I have read IM haasrdom m ustiab mquimmens under Chapter 6.95 of the Catirer-
his Hcahh & SafcryCode, Sections 15505,15533 and 25536.1 undersrvM LOU if the Wilding
does not currently batt aanent. that it is my rcap.n,,biI nntily the oCetmort of the
Date
rcgovemems hichmsbemc rroi:eaan«ar,cert;Bc ora
Signature of Applicant
All roof coverings to be Class "B" or better
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