05010047 CITY OF CUPERTINO 2!ta «« > tt � � tea6BUILDING DIVISION cON'T VT RMT5IN� N
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IT
ILDING ADDRESS: GURU ELECTRIC PERMIT NOO 5010047
NER'S NAME: PERMITISSUBDATR
TACO DEL MAR 1911 RESENTILEE CIRCTJ� 01 /07/2005
ONE: SANITARY NO. CONTROL NO.
(408) 254-4464
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION
0 F 1 hereby affirm Nu 1 am lisenscd under previsions of Cheprcr 9(commcncing Job Description
with Section7M))of Di i4ion3of Ne Busincuand N.fcuium Codcmlmyliccmcis
+ � infull force and affect. REVISION--IN HOOUSE .USE ONLY
?M4 License Class Lk.g
i
Data Contractor NO NEW PERMIT ISSUED ORIG. 404100065
ARCHITECTS DECLARATION
F 1 understand my plans shall W used As public records
5y
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Licensed Pnrfcuional
g
OWNER-BUILDER DECLARATION
2 f I Wrathy affirm on 1 1. camps from Ne ConvectorsLicense: c Law for tW -
OO which ngmama. ermit"7o Lr Business and ver demolish.
Code:Any city or county -
z m which oils s Issuance.permit pa enoatthe ahco improve,demolish,sire pair ed swqum
_Z� pdono its mied also req.the loan.of far sucCo m sit, U...Law(Chapter
-
O (commecingwidpunuan70XBofDiviomnfNCContrumsandPrmisonsCodur9 Sq. F[.Floor Area Valuation$56"
ES�Sp$
that
s marpt
ad the
Divisionrnf the
eged Business Any
Code)or
C 3.- Nat he 4 camps thcrtfmm and the buts for the alleged exemption.Any vielalion of
Section 7031.5 by any applicantfofa Permit ubjects the applicant in a civil penalty of APN Number Occupancy Type
not more than five hundred dark.(55001 p y yp
❑1,As owner of Ne pmpwy,or my employees with wages u their sole compensation, 32627035 ' 00
will do the soh,and time structure Is not intended or offered for sale(Sec.7044.Bosoms
and Professions Cod.:The Commutes Littnm law does not apply W an owner of Required Inspections
property who bulldsorimproves Nefeon,and who doessuch work himself or Nsough his
awn employees,provided that uch improvements are not intended moffened for sale.If.
however,she building or improvement is wild within am year of completion.the owner- A
builder will haw:the burden of proving that M did not Wild or improv for purpose of
it
O\
a owner of project
property,,B exclusively and confessional with licenced eonuuran to \
ewW es not (Sec.7014,Business red Professional Wi CodeI The Convacun,and.
law doer not apply m m owner of DrvpenY who Wilds or improves thereon,and l`l
ontracts for such projects with a conractor(O licensed Fursmin m the Corm ctols
e law.
m exempt oder Sec .B&PC for his mu
r e �
WORT COMPENSATION DECLARA
Thereby.M...derpenallyofpeduq...f Ne ing declarations:
aw and will maintain a Certificate of Comenuo self-insure for Worker'.Compen-
ation,As Provided fm by Section 3700 of dm labor Code,for the Performance of N. -
wmk for which this Permit is issued.
❑1 ban and will mainuln Workers Compensation Insurance,as myvined by Section
3700 of the Labor Code,for the performance of the work for which this Permit is issued.
My Workce,Compensation Insurance carrier and Policy,number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
ribi.socllon reed not W completed if the permit is fmouehundred dollar.(SIM)
orleu.)
1 certify that In the performance of the work for which this permit u Wood.I Nall not
employ any pawn in my manner an u u,become subject to the WorkeK Canpew0on
Laws of California.Dam
Applicata
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject so the Worker's Compensation provisions of the lahm Code,you most
70 forthwith comply with such provisions mitts permit shall W deemedhawked.
z
(z) CONSTRUCTION LENDING AGENCY
1 W reby AM.that Nem its comtmetun lending agency to,the performance or
Yr
the work for which this permit is issued(Sm.3097.Civ.C.)
Q Islder's Name
z Unde,'.Addma /
;)0 1 cenify that I haw read this application and sate that the a Wve information is
y contact.l agree in comply with all city and county ordirunas and sue law missing a
^may U Wilding constrvctlon,and hereby sunbeam hapresenuHws of this city to cater upon the
NWS shove-(We)A Wproperty for indmnify An Amba.
(We)agma m ave,indemnify and kap harmku the City of against id City
yrA Ilebilidu.Judgments.costs and lots ofthis esmit. may In any wyacme agdnwl aid City
J 7 APP. ucMcUND""NAANDWILL COMPLY WITH ALL NOWPOINT Issued by: Date
tom— SO REG L TION . 6 4
Re-roofs
tpefibure of Appli6a.dComill,19iDau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ihe.pplicanl ser(uwm Wilding occupant slorc or hendis huudous material
enned by tie Cupertino Municipal Code,Chapter 9.12 and the Hasltit and Safety
de.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
Ya u
Will the applecsm sir fmaha building occupant use rynipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
II haeaednos air contaminants as daIgmd by the Bay Area Air Qualify Management all new materials for inspection.
District? -
❑Ycs u
I how mad the hazardous materials re,bomenu under Chapter 6.95 of the Calif¢-
ria Health&Safety Code,Sections 25505,35533 and 25534,I urdermand its,if Ne Wildint
d of c" 'I haw a tenant dos It u my,u susilhilily ro mol'y tic occupant of th.
rc cram hi mu 1pdoruinuanaofsCcnibateo apaney. Signature of Applicant Date
O b d All roof coverings to be Class "B"or better
water ur amhori.c0 ager a