04080257 CITY OF CUPERTINO -' `"•')°_ '' "'�•' - " ' "•""a -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION;,
BUILDING ADDRESS: PFAMIT NO04080257
10122 AT)FT.HRTT) rT ---
OWNER'S NAME: PERMIT ISSUE DATE
BROOKS FTSHER A nn
SANITARY NO. CONTROL NO
ARCHITECNENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH '
uo`p LICENSED CONRACTOWSDECIARATION lob Description
w❑ 1 kmby affirm that 1 am"nosed under revisions of chapter 9(commencing
P
iw wnb5 eon Q7U Dimm�3afthc Bum Pmrmesiaiu COk�.vydmyliccvc ix
<n immure once a 2L�1 UPGRADE KIT/WINDOWS/HALL BATH
Licenm s L' .M
��o a a•�-^<- CONTRACTOR: KAVANAGH CONSTRUCTION
AR HITECTS D LAI N U
to 1 understand my plans shall be used as public records
JU
3 0 l Licensed Professional
` S Our lam exempt( DECLARATION
1 hereby al0rm them 1 am exempt from tk Contractor's Cc License Law for the
p O following rtuon ($CCdnm](1315,Business and Nvfessiom Cade:Any my or county
aa�m whim requite a permit to corer.,alwr.impra s,demolish,m repair any suucum,
poor In its issuance,also rrgmres the applicant for such permit to rile a signed sutement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft, Floor Area Vaasltiqo 000
ne (commencing or the Section 7MKO of Division 3 of the Business and Professions Code)or v
i $
that he Is eaempt therefrom and use basis for the alleged cumptiun.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type
Out mace team five hundred dollar($500). 3 5709025 . 00
01,as owner of the property,or my employees with wages u their sole compensation,
will do the work aw the swemes is not intended or offered for sale(Sec.7044,Business
and Profcssmm Code:The committee Ceave l law does not apply to an owner of Required Inspections
property who builds or maroons thromar nd whodmssmh work himselfor through his
ownemployee,provided pnsuch improvementsartnot attendedmpleeredforisleIr-
builder the building orimpmvemvins sold Within one Wild of impromfrNe owner- t
budder will have the burden of proving that he did not bored or improve for purpose of
We.).
❑1,a,owner of the property,am exclusively contacting with liaved ronvacwrs to
construct the project(Sec.lane Business and property who Professions Cade:)The Cameacon.Li-
cevc Law does not apply e u owner of property who Wilds p as improves themom.and
who commas for such proleets with a<ontamor(q licensed pursuant m the Canmanmr'e /
License License law.
❑1a opt under Sec. .B@ P C for Nis rtuon
Dal
WORKER'S COMPENSATION DECLARATION O(�
I harcby aRren under penalty of perjury am of the following reallocations: V
bare and will maintain a Ccmfiate of Consent to self-insure for WaftesCompen-
sation,as provided for by Section 3700 of die labor Coda,for the performance of the
work for which Nis unnu w iumd.
0 1 have and will maintain Worker's Compensation Insurance,as recruited by Section
3700 of the labor Code.for in, osmancc of the work for which This permau issmd.
My Work Cc emotion lore ce eerier and P/oBcy number am:
�itsier. Policy Na.. �
CERTIFICATE OF EXEM MONFBOM WORKERS'
COMPENSATION INSURANCE
(Thusecmmreed notkeampmteddthe pct are permit,hundred dollars(5100)
or less)
1 expiry that in the performance of the work for which this permit is heard,1 shall not
employ any person in any manner x v w become subject a the Worked Compevauon
Laws of Cahfamia.Dar'^
Applicant
NOTICE TO APPLICANT.IL after making this Ccmficale of Eacmpuon,you should
kcome aubjrO to the Worker's Compensation provisions of the labor Code,you must
Jz faMwith comply with such pravmnv or NU panto shall be deemed mvaried.
Z'O CONSTRUCTION LENDING AGENCY
(-. I hereby after that then is a construction lending agency for the perfunnance of
the work for which this permit is issued(Sec.3097,Co,C) _
Lg7 Londces Nar^^
z Loader's Ad,i •
U O 1 certify that 1 have mad this application and sate that the above Infuriation is
O.f" torten.I agree to Comply with all city and county ordinances and star laws relating to
O V budding constitution.and hereby suthonu reprexnuuves or this city to enter upon the
x U alwvc mentioned property for imupccu in purposes
(We)agree to save,indemnify and keep harmless the City of Cupemno against
F'nj i m oser enter,man""'and espt,nscs w:ch mry m any way accmc against said City
C.) z mconseyuence anhng afths permit
APPLE E ST ND NO WILL COMPLY ALL NON-POINT Issued by: Dale
50 ERE Q
tQ-31-o
Re-roofs
Signiwre of XOO man "interim '
Data
HAZARDOUS ALS DISCLOSURE Type of Roof
Will the applicamet fomu her accupanewro or handle WO rdous matenal
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ewe.perms.25532(.)' 14ug, All roofs shall be inspected prior to any roofing material being installed.
� Will the applicant or future budding occupant use equipment or dcvias which If a roof is installed without first obtaining an inspection,I agree to remove
t la.dov air contaminants u defined by the Bay Arta Art Quality Management all new materials for inspection.
am c0
0 Yes ®6u—
I have mad the havallous materials reyuimenns under ChapmrG95 critic Cahror-
nuHCalth&Safny ,Secures 25S05.2S533aw 2553d.lundcrsiaiid thazifdr building
Jars c n a s nano M rt. 5 3 anal755i 1 noaly the occupant of the F _ __
rey mmcros k poor loosmkcco care of y
a _07 Signature of Applicant Date
Dwncror authorized I'M �`` — Dam All roof coverings to be Class"B"or better ��