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CITY OF CUPERTINO
CCINTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS
PACIFIC NORTHSTAR MECHANIC
ILEBMITN04100150
10465 MARY AVE # A
OWNER'S NAME:
PERMIT MSUE DATE
CASA DE ANZA HOA
10381 N PORTAL AVE
10/21/2004
NE:
SANITARY NO. CONTROL NO.
(408)568-0287
ARCHITLCrIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
o
Jb Description
Chapter 9 (comencing
I hereby affirm that 1 am licensed under Pmvisions.f m
p
With Section 7000) of Division 3 orders Business and Professions Cede, end my license is
in fall force and crilicbM>0,\
REVISION --IN HOUSE USE ONLY
'tweraeorus LN Lic.N
D1}In L amlmmor
NO NEW PERMIT ISSUD/ ORIG. #03090187/
I
ARCHITELT3�EG A ATION
#03090188/#03090189/#03090190/#03090191/
I understand my plans shall used as public Accords
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Pmfeesions Code: Any city or county
Which mquirct a pmmit to mnsvua, ratersimprnve, demolish er repair any nruetum
prior,, its issuance, also requires the applicant forsuch permit m rile a signed statement
that he is licensed pussurind to the previsions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(core meneing with Section 700) of Division 3 of the Business and Professions Cole) or
0
Nal he is exempt unconfined and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects she applicant to a civil penalty of
APN Number
Occupancy Type
P Y YP
not more Nan rive hundred dollars ($500).
1, as owner of the property, or my employees with wages as their sole compensation,
will do Ne work, and the swcmre is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Convector's License Law does not apply to an owner or
property who builds or improves thereon, and who does such work himself or through his
own employees, provided thin such improvements are not intended or offered for sale. If,
47
however, she building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving Nat he did not build or improve for purpose of
v
sale.).
n
❑ 1, as owner of she property, am exclusively contracting with licensed convenors to
construct the project (Slow. 7W, Business and Professions Cade) The Contractor's Li
`4e
come Law does not apply to an owner of property who Wilds or improves thereon, end
who coreracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License taw.
❑ 1 am exempt under Sec. . B & P C far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the fallowing declarations:
10
1 have and will maintain a Ceniream of Consent to self-mome for Worker's Compere
siamn.m provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37M of she tabor Code, for the performance of Ne work for which his permit is issued.
My Worker's Compensation tax. ce carticr and Policy numMr are:
Camel: 5"btt 0 Policy N..: l�'65670 Y/
CERIFICA OFEXEMPION FROM WORKERS'
COMPENSATION INSURANCE
(Thisacction need notlacomplewd lithe ldri itisforrem hundred dollars ($I0)
or less.)
Ittnify that in the performance of the work for which this perm it is issued, l shall not
employ any person in any manner on u to become subject to the Workers'Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Ceni fieaw of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you as,
forthwith comply with such provisions or this permit shall W deemed mveked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nal there is a construction lending agency for the Performance of
Use work fur which this permit is issued (Sec. 3007, Civ. C.)
Lender's Name
Lender's Address
1 certify Nat I have read this application and saw that the have information is
cored. 1 agree to comply with all city and county ordinances and stare laws relating to
building conswnion, and hereby autherim representatives of his city to enter upon the
above mentioned properly for inspection purposes.
(Wo) agree to save, indemnify and keep harmlcv the City of Cupertino against
liobilities,Judgmcnts, costse Cxpenaes Which may In any Way aCCNe againstsaidClly
in consequence or the 9 soft of this Permit.
APPLICA UND RST 'IDS AN /IL C6MPLY WITH ALL NON -POINT
Issued by: Date
SOURCE .GUI A IONS
Re -roofs
Type of Roof
(J
Ignwur rAp a -c.nt cmr out
HAZARDOUS MATERIALS DISCLOSURE
ill the applicant., future building occupant store or handle haaardous mawrrial
az do red by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Co,Societe 255R(a)?
❑Yet I�N.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipments devices which
,it hmardous air contaminants se defined by the Bay Area Air Quality Managamcnt
all new materials for inspection.
- Uistricl?
❑Yes
I hove mad the havamoes maweials requirements under ChaPwr6.95.f me Cubbe,
r
ria Health & Safety Gtde, Sections 25505.25533 and 25534.1 understand Nat if the building
does mol a "' have a tenant, at it is my responsibility m notify the occupant of Ne
mquirc .tswmmana hcme rimwiaatrancc.raccmrcawprac.P .y.
Signature of Applicant Date
All roof coverings to be Class "B" or better
own
.r as orimdagcm Date