03010061 CITY OF CUPERTINO ""
BUILDING DIVISION PERMIT C0NTRACT0R4NF0RMATIOr1!tIis "
BUILDING ADDRESS: MULFORD ELIZABETH P PERMIT NO.
10366 TONITA WY 03010061
OWNER'S NAME: APPLICATION SUB DATE
MULFORD ELIZABETH P 01/10/2003
]ONE: SANITARY NO. CONTROL NO,
ARCHITLCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t00 LICENSED CONTRACTOR'S DECLARATION (n rte` - I
a I heathy affirm Nat 1 am licensed under pnwisions of Chapur 9(commencing ?v Job Description
G2
with Section of Division 3 of Ne B Others and Professions Code,and my license is '^' \ /„ note
r¢m. ELECTRICAL UPDATE
laI ` I
ZoZ LMcnre Class Lica
O Z F O Date Contract.,
0 QQ ARCIInF.CTS DECLARATION 2 I undtmand my Plans shall he used as Public records
yU
t�sFLL py2 Licensed Pmfess]onal
j OWNEBUILDER DECLARATION
mm 1 heathy affirm that 1 amm exempt from the Cnnwcun's License Law ln ithe
sav 00 following reason.(Second 703 1.5.Business and Professions Code:Any city or county
g 6� which requires a Permit In construct,alter,improve,demolish,or repair any structure
,3< poor to its ismance,also requires the applicant hu such Permit o file a signed statement
ss that he is licensed pursuant to ove
to previsions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area 810 atlon
m (commencing with Scene.7")Of Division 3 of the Businessand Professions Code)or
$ that heis exempt therefrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of -ibX"NfWbI Occupancy Type
not mom than five hundred dollars($5110).
I,as owner of the property,or my employees with wages as their sole compensation,
384 111111 H
will do that work,and the arecturt isnot intended.,offered for It(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply Or an owner of 501 - FINAL TA`iS'GTNERGY
property who builds or improves thereon,and whoddessuch work himself or through his
own employees.provided that such improvements are not intended of offered for sat..If. 505 — FINAL ELECTRICAL
however,the building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
Conmmm the project(Sec.7044,Business and Professions Code:)The Contractors Lt. _
cense law does not apply to an owner of proptny who builds or improves Bmmon,and
who contracts for such projects with a emanations)licensed pursuant o the Contractors
Vnsc aw.
1 am exempt under Sec. B&P C for Nu mason
° IO rc94&,/-/0-C73
34 WORKERCOMPENSATIONDECLAI&LIMN
I herchy affirm under penalty of perjury one of the following declarations:
1 have and will maintain aCer iftcare of Conaenno self-insure for Workers Compere
sation.as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3]1X1 of the Labor Code,for the Performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy Nn:
CERTIFICATE Of E%EM PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm becompleud if the Permit is for nnc hundred dollars DIRB
or to..)
1 eenify that in the Performance of the work fur which this permit is issued,1 Nall not
employ any Person in any manner so as m beconm$Objecun the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ceniticau of Exemption,you should
became subject m the Workers Compensation provisions of the"her Code,you must
OO forthwith comply with such provisions or this Permit shall be deemed invoked.
z CONSTRUCTION LENDING AGENCY
[r r I herchy affirm Nat there is a consuuetionleneing agency for the Performance of
the work for which this permit is issued(See 3097,Ci¢Cd
0.Q Lender's Name
] z Lender's Address
U I eenify that I have read this application and sole that the above info,matiun is
D. F+ consul.1 agree to comply with all city and county ordinances and state laws relating to
O U building convection,and hereby a drone,represenulives of this city to enter upon the
above-mentioned property for inspection purposes.
L>, five)agree to save,indemnify and keep handless the City of Cupcnino against
fa. liabilities,judgments,coder and expenses which may in any way accent against said City
Ut-+ the gnfiin consequence of rang of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by:9 Date
SOI R�EEGULATIONS.Q,j ,{
J �f�ecF•'t� ,ca''�+"'—yr' '- Re-roofs
acre of AppucanUConuan r are
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safely
Gsde,Se lion 25532(a)T All roofs shall be inspected prior to an roofing material being Installed.
❑Yrs gallo P P Y g 8
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air Contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes jVNo
1 have mad the haasrdnus materials acquirements under Chapter 6.95 of the Califor,
ma Health&SafelyCode.Sections 255115,25533 and25534.1 undtrsund that if N.c building
does not currently have a tenant,Nat it Ism resgmsihility to notify the r ter of thc
rcyuirytncn hichmunMmetPoormi anccnf.CCNErauufOcc y. Signature of Applicant Date
Owner �`� All roof coverings to be Class"B" or better
Owner nmhoriud agent Date