04030264 CITY OF CUPERTINOfs
BUILDING DIVISION PERMIT CUN .". ICTQRIL�?k'C1 'ItJ,' Ii';
x'W"
BUILDING ADDRESS: DAVID VALVERDE PERMIT NO,04030264
OWNER'S NAME: PERMIT ISSUE DATE
SURJIT
E:
SANITARYN CONTROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_00 LICENSED CONTRACTOR'S DECLARATION `– Job Description
q U 1 Wreby affirm Nst 1 am licensed under pmvbicns of Chapter 9(Comm
p
with Sccdon70W)of Divlsian3of0 Bueinosand Pmfasaions Cadc.andmyliccMai
imfull force Add Affect. REVIEW
ION-- HOUSE USE ONLY
5 License Clue Lic.p
Dae na
C.mMir P T ISSUED ORIG. #04020154
ARCHITECTS DECLARATION
I understand my plans Mall be used As public memo
7
3 G
Licensed Professional
OWNER-BUILDER DECLARATION
1 Mrthy affirm that 1 sd exempt s-i the Contractor's License Law for to
s}Om Whiihin q.t.A. Panda 9(131.S,Bnalan.iand PmfC61a1n Code:Any city strumn,
,comy
$ which I%isoa n permit m slims the pier,improve,de permit
i,ri e pair any awcmm
FUZ< that hor nicecensed c,also pursuant
pro inion of for such f the Conlar mid Lim asigned ataumenl
FF p (commencingwJPurwendtthepmviv3ofBeBusiness nimnussionCLaw apter9 Sq.F[.Floor Area Valuation
C $ (eat he
(commencing 70(KB of Divisionihrn(tMeged exempt Professions Code)or
3�
that he b attempt therefrom and are Mei+far the alleged exemption.Any violation of
Section 7031.5 by any Applicantfor a permit subjets the applicant la A Civil Penalty Of APN Number Occupancy Type
not mac Nen five hundred dnilam(3500).
❑1.Cie owner of the pmpeny,or my employes wit wages As their sole Compensation,
will do the work.and the atractum is not intended or offered for...(Sec.7044,Business
and pmfeaamns Cade:The Commerce,License LAW does net apply M an Owner or Required Inspections
property who builds or improves thereon,and who does such work himself ar through his
..employ...provided talsuch improvements are nolinunded oroRered fasale.IL
however,the building or improvement is sold within one year of completian,the ownct-
builder will have the burden of proving that he did not Wild or improve for puryou of /
salt.).
I,as Owner of dw properly,am exclusively conducting with licensed contractors to
;ion,
swot de project(Sec.7014.Business and Professions Code:)The Convector's Li-
se Law dors not apply la an owner of Property who Wilds or improves demon.and,
conwcu forsuch prjects with A contracwr(sl licensed pumumt m lM Contractor's
Cne Law.
lam exam ' AS .B&PPCfllhisu.is
ONERS OMPEN ATION /SONI hereby affsm under penalty of perjury ane or Ota ol7 lowing declan0on:I have and will maintain a Cenifcam ofConsenlloulf-insumfaWorkareComPen-
u provided for by Station 3700 of the Labor Code.fa to performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insumna,in required by Section
37M of d o Leber Coda for the performance of the work for which this redid,is issued.
My Worker's ComMusa om Insurance carrier and Policy number Am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mosection need nodbecompleted if the permit Is fare=hundmddollars(SIM)
or less.)
I certify,that in the performance of the work for which this permit Is issued,l shall not
employ any person in any manner=As to became subject to the Workers'Compenetlan
Laws of Celifomia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject An the Worker',Compensation provisions of the labor Cade,you mot
.JO forthwith comply with such provisions or this Permit shall W deemed mmked.
Z� CONSTRUCTION LENDING AGENCY
[+ Thereby affirm that then is a construction lending agency far the Performance of
fYi 7 the work fur which this permit is issued(Sec.3097,Civ.C.) -
WM Q Lenders Name
z Lender's Address
U e 1 certify that I have died Ws application and lots that dm shove information is -
L4 F Correa 1 agree 10 comply with all city and county ordinances and are laws raiding u
O building conauucdion.tad hereby authode mPruenutives of this city to enter upon Be
U above-mentioned pmperty for inspection purposes.
gy (We)agree to save,indenify tad keep harmless the City of Cupertino against
m1
rA liabilities,judgments.costs and expenses which may In any way accrue against Mid City
U Z in consequence of the grMting of this Mandl.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL N N. Issued by: Date
SOURCE REGU TIONS
3 31 Re-roofs
Si m fApplicanUC vumr DAM
\ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building=upset store or handle havardoo mated.]
ss defined by the Cupertino Municipal Code.Chapter 9.12,and de Heald and Safety
Cade.Settle.25532(.). LLL��g All roofs shall be inspected prior to any roofing material being installed.
❑Ys ID No
Will the applicant or future building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hoardmua air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Diuric 9
[3 yea
1 have mal the harardnus materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if Be building
dean not C..%L,new a mmm.than it is my mspmuibithyI'�mAltmdl'y du occupant of the
wh
requiramcnts hmuu met pd to Issuance ora%/ f c Signature of Applicant Date
m,or agent / DEW All roof coverings to be Class"B"or better