03090218 CI'CYOFCUPFR'fINO3 ^ . .w, {,s - ,a �. a *I
BUILDING DlvlsfoN PERMIT ,CON"1`RACTnRNF�RMATI3,0N
BuII.DINGADDRESS: - ENVISION BUILDERS PERMIT NO.03090218
'R'S NAME: 3940 VIA CRISTOBAL PERMIT ISSUE DATE
NE: SANITARY O. CONTROL NO.
(408) 410-9054
ARCHITECT/ENGINEER: BUILDING PCRMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION
I Mrchy art".the,I am liars a&,Provisions of Cham er 9(commencing Job Description
ii wW cu n]IXMp of Divixion3uf thc0 u end Profcuiuv Code,end mylicenm is
=N in full condo t.
,q? tic Claeauc.« 1 6 REVISION--IN HOUSE USE ONLY
o Dale Corrector NO NEW PERMIT ISSUED/ORIG. #03070231
W ARCHIS RATION
i - hperetT rehash.I uredo public me res
50� Licensed Pmfc�t as
3 OWNER-BUILDER DECLARATION
<N I hereby affirm that I am exempt from the Cctractor's License Law for the
❑0 following motor.(Section 7031.5,Business and Pmfcssions Coda:Any city sem county
S$ which requires a pc mit''ou construct,offer,improve,Jemolixh,or repair any structure
-Z< prior it)its issuance,also noires the applicant(orsuchpermitm file asiland statement
thalhcislicenwdpursuanuothepmvisiouoftheConoacmr',Liccnmlaw(Chapter9 Sq.Ft. Floor Area Valuation $o.
ZFO (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
that he u exempt therefrom and the Buis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects fee applicant to a civil penalty,of 3 rA B1a hi�,.�ker Q Q Occupancy Type
not more than fin hundred dollars(S500). 'OLEN`Y`1Y O`�
❑1,as,owner orthe property,or my employees with wages as their auto compensation,
wdl do the work,and the structure is nor intended orarfered for sale(Sec.7064,Business Required Inspections
and de:Professions CoThe Centimeters License law does not apply to an owner of q P
property who builds or improves thereon,and who does uch work himself or through his
own employees,provided that such improvements are not intended or offered for tike It.
however.be building or Improvement is cold wfirm one year a(comple,ion,the awmn.
builder will have the burden of proving that he did not Guild or improve for purpose of
sale,). - �\
❑1,as owner of the Sec.porporty,,B acus and Professions with licensed convenoss to
construct the project(Sec.low,Business and Profusions Coale:)Them d Contractor's Li a r�who
contracts law coca nal apply m an owner of mropeny who builds rs imptovu thereon,and, \S
whonse for such projects with a conevemr(s)licensed pursuant to the ContnmaM1
License law.
❑ lam czcmpl under Sec. .Bk PC for this moon
r Data
WORKER'S COMPENSATION DECLARATION
I hereby afnnn under Penalty of perjury ane of one fallowing declarations:
I have and will maintain a CeniGcate of Chuen,to self-insure for Worker'sCompen-
saton,as provided for by Section 37W or the Labor Code,run the peffommance of the
work for which this Permit is issued.
I have and will maintain Workers Compensation Insurance,as acquired by Section
3700of the labor Code,far the performance of the work far which Nis Permit is issued
My Worker's Compenurion Insurance carrier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mos section aced not ha completed kf the Fork is for ome hunered Millan(5100)
less.)
1 cenify that in(he performance of the work for which this permit is Issued,1 shell not
employ any PcrsOtN mappers u�uf ggsy`jecl to the Workeri CamPensellon
Lawsof Cali 1rAf I `�
ApPlkcam
NOOr[ICf�sTOA7in the Worker's
atommdmg this previsions
of of E abrtiodyoushould
We
ith,aomp to it Worker's Cumpcor Oil, provisions of the freed Code,you must
,�' (or uh comply with such provisions or this Permit shall M deemed rerokeJ.
ti O CONSTRUCTION LENDING AGENCY
I hereby onem that there is a convection lending agency for the perfurmantt of
Yi the work for which this permit is issued(Sec.3097,Civ.C.)
a] ALender's Name
3 z Lcndcrs Addreu
Q 1 cenify that I have feed this application and sum that the above information is
correct,1 agree to comply with all city and county ordinances and state laws relating to -
�U building construction,and hereby atdhorim representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
y (We)agree to save,indemnify and keep humorless the City of Cupertino against
N liabilities,judgorenW costs and expenses which may in any way accrue against said City
J z to consequence n tis
APPLICAUNDERSTAoS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E U ATIONS. k
Ah Re-roofs
Plate gnemrc fApPlicaHAZARDOUSMATERIALSDISCLOSURE Type of Roof
Will the applicvm tar furore building occupant norc or handle hvvarduus materiel
as defined by the Cupenine,Municipal Code.Chapter 9.12.and the Health and Safety
e.Section 2553:(a)7
❑Yes ®Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air comaminents u JCOncJ by,hc Bay Arca Air Quality Managcmcnt all new materials for inspection.
,strict?
❑Ycs (fNtr
I have nal the havamlI. mammals requion,marnJct Chapmfh.95af the Cadfo>
ria Health&Safcl Code,Seen 25505,25533edZKH4.1 undenwnd Mifthe building
dors not curtentl hove a tens ,Nat it is my acspomibitify m nadfy t occupant of the
requi swihmustbc Ifourtoissuanaof.1couleaoof cupgpc I Signature of Applicant Date
0 amhonrccJ open! r All roof coverings to be Class "B" or better