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CITY OF CUPERTINO
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PERMIT
CONTRACTOR'INFORMA-TION
.,
BUILDING DIViSfoN
BUILDING ADDRESS:
ANN VIDIA
PERMIT NOO4100013
OWNER'S NAME:
PERMIT ISSUE DATE
ANN VIDIA
NE:
SANRARY O. CONTROL NO. -
ARCHITECVENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
- Job DaSCnptl -
I hereby afbmt that 1 am licensed under provisions of Chapter 9 (commencing
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with Section 7Q9D)of D1vhm.3oflhe Businea and Profession Codi.end my license is
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Laurorca effem.
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REROOF W/ ASPHALT SHINGLES
License ClassLk. g
s
Date Connector
ARCHI SDECLARATION
— "-' - — - �- - - - - _-- - - - - -
1 undimmnd my plans shall k used as Public records
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OCT
C� -2004 - -
Licensed Professional
DECLARATION
OWNER-BUILDERDECLARATION
Oat
pe
from License Law for the
I am exempt from Ik
I hcnhy affirm Nn I
following mea m. (Section WD 1.5, Business and Professions Code: Any city or county
®J
Li'
which raisins a pernlll tel connNel, aBef. hnproxe. derimish, m repair my SWctux
prior in its issuance, also mqums the applicant for such Permit to rile a signed smmmem
tisane law
Sq. Ft. Floor Area
Valuaton
that he is licensed punuanuo the provisions of Nc Comnerms Chapter
(commencing with Section 7") of Division 3 of the Businesaand Professions Cade) or
dust k is exempt therefrom and the basis for the alleged exmption. Any violation of
3 269TUtulirlintO 0
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Occupancy Type
Section 7031.5 by any applianl fur a permit subjects the applicant to a civil penalty of
not mom than Five hundred dollars (S500).-
❑ 1. as owner of use property, or my employees with wagu u their mile compensation,
Required Inspections
will do the work• and the structure is not intended or offend for sale (Sec. 7044, Business
and Pm&vlum Code: The contractor, License sew does net apply in owner or
propeny who build, orimproves themionand who docasuch wmkhimaelfor through his
awn employees. provided that such improvements ase not intended oroRered forsale.If.-
heonmr. due building or impmwmenl issaid within one year of completion. the owner.
builder will have the burden of proving that he did not build or improve for Impose of
sal, ).
❑ 1, as owner of the property, am exclusively contracting with licensed contraction to
convertor Ik project (Sec. 7044. Business and Pradmioes Code:) The Contractors Li -
'-
ecru law does not Apply to an owner of property who Wilds or Improm thercom, and
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whocontractsfor such projects with a connamr(s) licensed punuant to the Contractor',
..
tcanu
1 an �u rep -t uendo, Sec. B & Cris azo,
Owl �,,N,
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WORKER'S 1PENSA 10 J RARA�O
I henry arrum under penalty of perjury oro of a filr olloWing declamations:
Ihaw and will maintain a Cardfican of Consent self-iesum for WorkcesCompcn-
sarum, as provided for by Section 3700 of Ne labor Code, for the performance of ft
sent
work for which this Permit is issued.
1 have and will maintain Workels Compensation Insurance. es rcyuimd by Section
31. of Ne labor Code, for the performance of Ne work for which this permit is issued
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My Worker's Compensation Insurance corner and Polity number arc:
Cartier: Policy No.:
CERTIFICATE OF FXEMP ION FROM WORKERS'
COMPENSATION INSURANCE.
m
(ruse it. need ret kcompietw if the Permit isfor,nchundrcd dollars (SIM)
mle".)
I terrify Nat in the performance of due work forv/hich data Permit is issued, I shall not
employ any person in my m rte nn/mhecmbfs tk Worked Competuauon
Law, of California.�J LGG� �R'.a�T�
Applicant
NOTI TO APPLICANTW,. VI milki�ngWs cCznl ti' tE{s n, you should
become act to the Workers Compensation previsions of the lakr Code, you mus
' fonN th comply with such provisions or this Permit shall k accrued revoked.
LENDING AGENCY
j CONSmisa
construction
1 hereby ilium that then is es ron(Sec. 30 tending agency [or tk Performance of
' ate work for which this permit u rums (Sec. 1097. Civ. G)
tinder's Name
LcndeYS Aad,ea
j I certify that 1 have read this application and slate that Be about information is
' correct I agree to comply with all city and county ordinances and sus¢ laws mlating to
buiiw-romconstruction,roperty hereby amhorix,mras. representatives of this city reenter upon the,
for
akvcros,
7 nmpcny epcwo, purposes
(we) agree to saw, indemnify and keep harmless the City of Cupertino against
j judgments, which may in any way seems against said City
in covequcr¢e of ire granting of Nis pe is
incoursequnicaft¢•cousantif *Is,
' APPLICANT UNDERSTA S AND ILL COMPLY WITH A NON -POINT
Issued by: Date
E RE LA _ _
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Re -roofs
Type of Roof
un of Applic onnactor a¢
HAZARDOUS MATERIALS DISCL u
Will the applicant or future ruilding occupant score or M1andlc harudous material
as deMcd by Ik Cupertino c pal Code. Chapter 9.13, and Ik Health and Safety
uNa
ewe, Scetien zsslz(.n
pt'es
All roofs shall be inspected prior to an roofing material being
P P Y g g installed. _
If a roof is installed without first obtaining an inspection, I agree to remove,
Will the applicant or future building occupant use equipment at devices which
mit bmardous it comamtnants as dc0ncd by the Bay Ana Air Quality Managcmcnt
all new materials r'nspection.
District? ��`��` //////
❑Yes �No
Sed,ss materials myvimmcna under Chapter 6.95 of the Calif.,
af` wc,Sccuma 25505, M533 and 25574.1 unMrnand thus if lk kildin
Ihave and the M1a]usixt
J
cm w a ant, that h h my respomibility m nouly We o cuymt of
meal mmp�ormixamteeocenneate,rC<te
Emoind
gnatureo Applicant Date
All roof coverings to be Class ••B" or better
ager ,te