05030027 (2) CITY OF CUPER7'iN0 > ? ^*'a` ro I * `
BUILDING DIVISIONPERMIT P CONTRACTOR INFORMATIQ
BUILDING ADDRESS: MARVIN DAVIS CONSTRUCTION PF"M"TN65030027
OWNER'S NAME: PERMIT ISSUE DATE
ER
"'ONE: SANITARY NO. CONTROL NO.
(408) 975-0200
CHITEC(ENGINEER: BUILDING PERMPI'INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+O' LICENSED CONTRACTOR'S DECLARATION
wC 1 Wrcby affirm Nal I am licensed order provisions of Chapter 9(commencing Job Description
W with Section'R100)oroiviai^n 3 ofthe Business and Profession Code,and my license is
o� in fall to=and effect. REVISION-KITCHEN REPLACE BEAM
j i License ClassLie.0
;o Da Contractor ORIG PERMIT 05020114
ARCHITECTS DECLARATION
E-� I understand my puns shall W used as public records IN HOUSE ONLY-NO NEW PERMIT
M
7iU
G In Licensed Professional
OWNER-BUILDER DECLARATION
i1 hereby sffirm Nal 1 am exempt from the Convectors License Law for tW
00 following mason.(Section 7031.5.Business and Professions Cole:Any city of county
m which requires a Permit to mmwcl,alter,improve,demolish,or repair any structure
prior to tem issuance,also requires the applicant for such pormiuo file a signed statement
that he is licensed punuamm the pmvisiom of NC Comrecori License Law(Chapter 9 Sq. Ft.Floor Area Valuation
(commencing with Section 70W)of Division of the Business and Professions Code)or
i $ Oat he is exempt therefrom and the basis for the alleged exemption.Any violation of 0
Section 7031.5 by any applicant for a Permit subjects the Applicant o a civil Penalty of APN Number Occupancy
mgt more than Tnw ane hundred dollars(SSW). P Y Type
❑1.as;owner of the property.or my employees with wages as Neu sale compensation,
will do the work and the structure is not intended or onerad for sale(Sec.Trust,Business
and Professions Code:The C^mncmrs License Law docs not apply m an owner of Required Inspections
pmpeny who builds or improws Hereon,and who does such work himself or through his
own employees,provided Nat such imprevemenu ase not intended or offend forsxle If,
however,the building or improvement u sold within one year of mearcuon.the owner-
builder will haw the burden of proving Nat he did not Wild or improve for puryose of `\
sale,. \\\\\\\
as owner of ct property,.Bexclusivelysinend confessions with:)Th,
mnfeacmrs i - ,^D
wo Nees at (Sec.in a Business and Professions Cade:)The ConuacWs n v�
who claw dines nm apply m as owner of propcny who Wilds or improve Ihemon.and
who contracts for such pmjecu with a conuanhr(s)licensed pursuant to the Contractors s
man law.
0 1
em exempt der Sec. ,Bk PC fares �\
owner - Dam 3 m Oash ``J\
WORKER'S COMPEN ECLARATION '
I hereby M.under penalty of perjury,one of Oc following decimations:
Moe and will maintain a Certificate of Chosen,to self-insum for Workers Compere
n,as provided for by Section 3700 of the ISWr Code,for Ne performance of Ne
rk for which this Permit is issued.
❑1 have and will maintain Wo run's Compensation Insurance,as mquiretl by Scnion
37W of NC Labor Code,for the performance of He work far which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi,scedon need notbecmnpleredir n permitisforhie Wndmddollars(2100)
or lass.)
I certify Hat in @e performance of Ne work for which this Permit is notice,I shall not
employ any person in any magwrm�tWbfcc bjeci to the Workers Compensation
Laws or Cal ifymi7a.Oate IAS// //
Applicant T L 'N
NOTICE T�PPLICANT:If,arm,making this Cenincom of Exemption,you should
become,object in Ne Wokei f Compensation provisions of Nc Labor Chde,you must
Z forthwith comply with such provisions or His Permit Na11 W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
F'^ I hereby dorm that there iso construction lending agency lot the performance of
C He work for which His permit is issued(Sec.3097,Civ.C.)
[glQ Lemicri Namc
Lender's Address
V C 1 mnify Hat 1 haw mad this application and two Hat the above information is
correct.I agree to comply with all city and county ordinaries and suite laws reining to
V Wilding convection,and hereby authorise rcyreemadws of His city to enter upon tK
W above-mentioned property for inspection purposes.
G (We)agree m sew,indemnify and keep harmless the City of Cupertino against
F"VI liabilities,judgment.costs and expenses which may in any way accrue against said City
tJ z in consequence of nosing or Nis
r. 'A CA DERSTANDS A ,COMPLY WITH ALL N N- OINf Issued by: Date
SOUR ULATION`�.
3 2 Re-roofs
Signauffe of ApplicanVChnmacor I Die
HAZARDOUS MA IS OSURE Type of Roof
Will the applicant or future Wilding occupant store or handle hvallous material '
as ill by f Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code,Sc❑cties 25532(a)? 0 All roofs shall be inspected prior to any roofing material being installed.
Yes
Will thea rant mmre buildin occu ant usee ui If a roof is installed without first obtaining an inspection,I agree to remove
PP 6 P a it Qu or devices which g
I hazardous air conmminans u Jcfincd by Nc Bay Arca Air Quality Management all new materials for inspection.
rt
C3 Yes
I haw mad He hamidous micrigi�requirements under Chapter 6.95 of the Califon
is HmIO&Saf Code,Socuo I5,d5533md3553s.lund..dNiif Oc Wilding
does not to fey how sin Net' yresponsihiliydnouly the ac senor the
myon uwhichmui met misshancehhcertinuatehrOc Pan y. Signature of Applicant Date
�z
or ahNonzed agent Date
b� All roof coverings to be Class "B" or better
Owner ,