00050207 CITY OFCUPERTINO' - PERMITNO.
BUILI[i R112N ADELHE MIMIT COO NT ►' ; '• i ' tfdP_•RfnT I ON rrmAA��,��Tttt
BUILDING ADDRESS, Me!1 ]-QJrl•9u
OHLER PETER "C AND LYNNE D 461 PERRYMONT nNlrn.Y NO APPLICATION SUBM TTAL DATE
OWNER'S NAME NIC
HONE:
ARCHITECTIENGINEER (4'08) 279-1911
9111TAINriJ1;ERMITjiNi;O�
�atz
00
a ae
f•>7 LICENSED CONTRACTOR'S DECLARATION '
OZ=p 1 hereby affirm that 1 am littn.d alai provisions of Cluper 9(commencing Job Description ,
F=Fd withllimm 7000)ofDivirson3of the Bu.tm.e wtl Pr.feuionv COde,Wmy hanxe t.
�s�a Ucelme CI coil �ect.
s a �TECrSDECLAR RAC R AND R FURNACE, ADD 0 A/C
�� I understand my plena sM1ill be uad a Public records
of
a Eno Licwd R.reataml
ad_ua OWNER-BUILDER DECLARATION
f-Z< 1 hereby affirm that 1 sm exempt from the Concro mrs License Law for Ore
❑ follow..... (Sect, 7031.5.Bumness end Profeuum Cade:Any airy s county �•rt:.�-
°�. which require a penal to comweL alter,improve,demolish,or rcfair any mmemre Sq. Ft. Floor Area - Valuation
prim to de issuance,also requires the awlmam for such permit to the a signed statement
that he is licensed pursuant to the provisions of the ConnamY.Liana Law(Chapter 9
(commencing with Smile.7")of Dtvtsion3 atria,Buaneaa and Peefuaom Cock)or APN tit) �`=7• m0 Occupancy Type
that he is exempt tha,from W the buts for the a ie W cu emon AnY violation of P Y YP
Salon 7031.5 by my Where,for a pemu subjects the Wieser to a civil family of
am mart then five berdrd dollars($500)
❑ Lee owner of de,pmpenY•mmY emploYcel with wages tee theinolc compemwon, 1 Required Inspections '
will dome work,andtheawcum,hied doeded moRemd fonal.(Sm 7014,11mtxere
and Profeaiom Code:The Comemer'a Liana law does nil apply to an menu of
property whawdm ortmpmve.threan,rand who does each workhimself ortwough 204 — UNDERFLOOR FRAME
his own employes,provided th•t such improvement,are not ine ded or offered for -
aide lf,M1.weer.mewndmgartmpm.,memia aamwmmaM yemarcamvlaian.the 301 — ROUGH PLUMBING
mwoa�najr will have mebardenofproving that heddnm Wild or intpm.efmpar.. 303 — ROUGH MECHANICAL
I,as owner of the property,am exclusively contracting with)loaned convenors to
c...roar theprocet(See.7w4,Basin.mad RafeaiamCd,:)TheCan.arol.U. 304 — ROUGH ELECTRICAL
,a.Law tla,eat.pply1.anaw.ofprapnywhaWit&mmpavmmmeme..nil 505 — FINAL ELECTRICAL
who o.'s far such pmpcv id,laoovm'.01)hcresd Protect m the Ca mixectee, ,
Le,wxe Law' 507 — FINAL PLUMBING
❑1 am exempt under Sm. .B A P C fm thta rcuan
508• — FINAL MECHANICAL
Owner WORKER:SCOMPE.NSATIONDECLARATION 514 — FINAL PUBLIC WORKS
1 hereby affirm seder penalty of penury one of the fdiwdng dslanuam
'1 Mve sad will munuin a Cemfir•..of Conernt m self-insure far WOkeYe Compem
rain,u pmvidd for by Section 3700 of the Labor Code,for the performance of the
ark for which mu permit m tamed
❑I have ed will maintain Worker's Composition Insarerva,u reps by Section /�
3700of the 46n Code,fon the mcameof the work for which this permit is,sud.
M1 WOrkeY Com on u ttcamce.d Policy
Cod ` • Policy No
.CERTIFICATE OF &F`171ON FROM WORKERS' ` O
COMPENSATION INSURANCE /
(This seat..needtut becomPind RdR perms is for one hudreA dollars(SIM)
a less.) `
I rmitr Out in me p d..c of the work for which mitepemm rs issud,lshall
rot employ soy person to any tmnar m as to become soldier to the Wortrn Comprn-
sdun Law.ofCddomia.Dat-
Appltcanl
NOTICE TO APPLiCA W:IL after malung that Certificate,of Exemption,you should
become wbje t to the Workers Compenstion provtau a of the Labor Code,you must
forthwith comply wit such provisions or mis petmlt shall be domed revoked. '
CONSTRUCTION LENDING AGENCY
I fix which do wr there is a ced(See 3n l7.Cis agency for the perfortnaae of
'the work for wh¢h the perm.n unud(Ste.3097,Civ,C.)
E. Lenders N.-il .
p� toer s Addres-
0. 1 certify,thus I have with this application rum mor and surd,Out the above infomution is
Ge corral.I agree m comply wim d1 city aid ewnty mdwnas W mate lows r own the
V O move-aeucreed ro wtl hereby authdu repteuntauvs of downy to enter upon the
abovo-tmnuond Property for inapecaoa Wrpo.el. ,
W t.. (We)agree to nova mdcmndy d lice,harmbut the City or Cupertino against
0 4,) ludal iee,judgmes,costs end exile which maymmy way same again said City
}
'T' to"no'me"of grwtin8 of sperm.
f• 0. APPLICANT ERS ND DWILL COMPLY WITH ALL NON-POIW
V z SOURC'Rf" T
Stg. amufAPPlic omrenor
HAZARDOUS MATERIALS DISCLOSURP.
Will theepphcmt or future bmldinSmcupwt store or hwdle herardous n¢nal Re-roofs '
u diined by me Cupertino Munmtpal Coda.Chapter 912,and the Health and Sdery
Cede,Smile.W3260? Type of Roof
❑Ye, ❑No
Will me epphctat or future building ncc.p.t use equipment tar devices which All roofs shall be inspected prior to any roofing material being•
mtthar iai aircontaminants adefusedbytheBayArcnAUQueiryM anagement installed. If a roof is Installed without first obtaining an inspection
m"' I a ree to remove all new materials for inspection. Applicant
❑Ys ON.
I have term the hararmw,maunala rtgatrtmant,adrr,Chapter b 95 oftle,Cdt- un erstands and will comply with all non point source regulations.
forma Health R Safety Cade,Sections 25505,25533 and 25534.I understand that if the -
bodmn®dacs nm cieremly mvc a e,nanL thus ins my rtsponmbdny m nmify me oaupwt t
i of the rtymrement,which must be met pimwuamnce ofeCentfcae,MOccupwcy. '
Ownermiamomd.ge.r Date Signature of Applicant Date
All roof coverings to be Class"B"or better
OFFICE