07010072 7:7 7777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT ® I ..'
PERMIT NO.
BUILDING ADDRESS:
55 PEPPER TREE LA AMERI PmMITT$SUEDATE
OWNER'S NAME: 1758 JUNCTION AVE, UNIT -D 01/11/2007
°11AKO I MAMURA
SANITARY NO. CONTROL NO.
'NE: (408) 436-8151
BUILDING PERMrr INFO
ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH
400 LICENSED CONTRACTOR'S DECLARATION Job Description
t m p 1 herebyaffirm that I am licensed under provisionsOf Chapter 9(commencing
eZt�n with Section 7ivision3oftheBusinessandPy�% P 3ypaagwia REMODEL 3 BATHROOMS NON STRUCTURAL
y in full force and c �lGJ7
n Z License ss
aLie.
F'j+ D LTSContractLAR 4 l
a rcen=cd
d p ,Z:R e used as public records
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u.y Lio a
< DECLARATIONrom the Contractor's License Law for the
�i 0 o roin (Section 7031.5,Bust Professions Code:Any city or county
1:0
Pi wpermit to construct,alter,impr demolish,or repair any structure
Z r pce•also requires the applicant for so Per
to rile a signed statement 3 .Ft.Floor Area Valuation
< thpursuant to the provisions of the Co. tor's Liccnsc Law(Chapter 9 q $30000
Yt= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3591201E .ARN Number
not mote than rive hundred dollars(5500). vv
❑1,as owner of the property,or my employees with wages as thew sole compensation,
will do the work.and the structure is not intended or offered for sae(Sec.70U,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sate.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B dr P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for WOrkees Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the LAbor Code,for the performance of the work for which this permit is issued.
My WorkV*s-?!ompposaLion IrM ranee carrier and Policy nuQtbc� O
C Policy No.: WORKERS'
CERTIFICATE OF EX Pr1ON FROM
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date—
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
py> the work for which this permit is issued(Sec.3097,Civ.C.)
W 0Lender's Name
aLender's Address
[certify that 1 have read this application and state that the above information is
LUL correct.I agree to'omply with all city and county ordinances and state laws relating to
0 V building constrttcti n,and hereby authorize representatives of this city to enter upon the
U above-menti d p perty for in ction ses.
t�' a (Wc) g e save•indc n y p harmless the City of Cupertino against
k. liabi jug en costs d whi h may in any way accrue against said City0.4 / —
;n co c f th g ti o th it. Date
V►�-� APPLI NO IL COMPLY WITH A NON-P INT Issued b•r:
S LA
Re-roofs
Sig ure h UCon te
HAZARDOUS MA DISCLOSURE Type of'Zoof
Wil the applicant or future building Occup ore or handle hazardous material
as dery d y the Cupenirm Muni.pal Code,Chapter 9.12,and the Health and Safety
Code, n 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant o future '(ding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, agree to remove
�l
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes u
( v re ehazardousma requirements under Chapter 6.95 of the Cal ifor.
nia H
act
ode,Seri 5, 5533 and 25534.1 understand that if the building
does y ave a a L. at is y responsibility w notiry Ute occu ant of the
require e c t 'o i uancc of a Certificate Occu Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner r th d age Date