04100118CI'I'Y OF CUPEW11NO
BUILDING DIVISION PERMIT
BC ONTRACTORp,INFORMATION
0GILDINGADDRESS :
MCKENZIE BUILDERS
PERMITNG4100118
0052 IMPERIAL AVE
0 W NER'S NAME:
PERMIT ISSUE DATE
NAILS 2000 NUY NGUYEN
855 HENDERSON AVE
10/18/2004
Nl,.
SANITARY NO. CONTROL NO.
(408)218-6252
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby affirm !hal l am licensed under provisions of Chapter 9 (commencing
With Section and if Division Jof NC Osincas an Profcwinns Codc, and my license is
inmSrti and r L
TI --WALL OPENING/
Ciccone i Lic.
^
Dmc a COmrac un. f '
ALE
��� (TsS DR `ON
1 undcrsnnJ my plans shall etc used a s rcc rd¢
sshall
OFC 2004
IJmncd Prarmsianal
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am eacmpo from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and pnRessions Code: Any city or county
which requires a permit or consumer, alteC improve, demolish, or repair any structure
$3500
prior to its issuance. also requires the applicant for such permil to file a signed inurement
Sq. Ft. Floor Are Valuation
that he is licensed pursuant to the provisions Of the Contractor's License Law (Chapter 9
(cum me acing with Section 7000) of Division 3 of the Business and Profusions Code) or
Na! he is eacmPt therefrom and the basis for the alleged cumption. Any violation of
b Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($5W).
1, as owner of the property, or my employees with wages as !heir able compensation.
Required Inspections
will for Ne work, and the strucfum is not intended or offered for sale (Sec. ](I4W, Business
and Professions Code: The Contractor's Lieu Law docs not apply to an owner of
property who builds or improves thereon, and whodaetsuch work himselfor through his
Own employes, provided that such improvements me not intended aro@red for sale. IL
however. the building or improvement is sold within one year of completion. Ne owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
[j 1, as Owner of tut property, am CXCLUSively COmmucling with licensed contractors to
construct the project (Sec. 7044. Business and Profusions Code:) The Contractor's Li
cense Law does not apply to an owner of property who builds or improves lheman, and .
who con, rncls for such projects with a contractor(¢) licensed pursuant to the Contractor's
Peru. Law.
I am exempt under Sec. . B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury, one of the fallowing declarations:
1 have and will maintain a Cenifuto or Coment to self -imam for Worker 'sCumpen-
wim , as provided for by Section 3700 of the labor Chile, for the perfomunce of the
work for which this ryrmi! is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of dom labor Code, for tha performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Carrier, Pulley No.:
CERTIFICATE OF EXEMPTION FROM KERS'
E
coMPENSATIONINSURA
(Thi¢ seclinn need not he completed if the permit is for one hundred dullan (g ND
err less.)
1 If Nal in formen of the work fm which This permit is issued, 1 ¢hall nut
he
employ any person inn. naso I!! glforwhic�aNC Woderi Compensation
c o
!Cal rd P L}t—�
npplijce,
TO 1 : If, of r king this Genion¢ of FLabor io you should
Code,
h RRR��ith the WorkersQ gtknsmiisprovisions of the Laborrvolouyou muss
'Xi
forthwith comply with such pro ms or this permit shall ho de coined mnkcd.
com!y
CONSTRUCTION LENDING AGENCY
I nor Na! than is lending agency far the performance of
s ed (Scclinn
Newark for wnich this permit is issued (Sec. JIN], Civ, CJ
which
Lenders
Lender's A" Address
1 certify that i have read this application and state that the above information is
' coffee, 1 agree to comply with all city and county ordinances and state laws mrating to
building construe!ion, and hereby authorize representatives of this city to enter upon the
for inspection
ahove-mentioned properly purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities.judgments, costs and ealwnses which may in anyway accrue againstsaid City
/t
ins race Of the gmming Of roue permit.
PLIC STANDS AND WILL COMPL WIT LL NO NPOINT
Issued by: Date l
souac�
Zf�Re-roofs
Type of Roof
Sr o HA n fneOUS MATERIALS DISCLOSURE par Dare
ill Nc applicant or future building Occupant store of ban Ic Ous mamrial
e etl by the Cupertino Municipal Code, Chaprer 9.13, and allh and Safely
Codc. Section 255320)7 �.
All roofs shall be inspected prior to any roofing material being installed.
P"", ❑ Nu
minre wining equipment err devices which
If a roof is installed without first obtaining an inspection, I agree to remove
wm the app' or occupant ane
dt nnmmna¢ wnmminanu u defined by the Bay Arca An pualhy Management
all new materials for inspection.
District'!
Yes ❑ No
I have read the bvardrmz materials requirements under Chapter 6' 15 of the Califon.
nia Health& Safely Code. Sections 25505.25533 and 25534.1 unitrsmnd Thu if the building
or a a tenant that it u my responsibility In notify IM occupant of the
afirea met 'arinissuanccora enia morOccupaney.
Signature of Applicant Date
th,cd
All roof coverings to be Class "B" or better
0 agent Dam
I