04110171 CITY OF CUPERTINO
BUILDING DIVISION PERMIT MCONTRACTaRNFURMATION �.:,
• BUILDING ADDRESS: PERMIT NO 04110171
10_�el ANN APRnR A177,
OWNER'S NAME: PERMIT ISSUE DATE
ANGELINE L
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION f -�
I Wmby.rhmr that I am licensed on&,provisions Of Chapter 9(commencing lob Descnption,�
i withSceion7M) of Division Sof NC Business and!Professions Code,and my license is
5 2 nfall form and effect. FIRE DAMAGE REPAIR \l�
License Clus Lie.N
4g, Dam Cantrumr
ARCHITECTS DECLARATION
V 1 understand my plans Asti W mcdu public records
az J J
;off Licensed Pmfcssional /�.�p//•
OWNER-BUILDER DECLARATION �JG
p 1 hereby affirm that I me exempt form the Contractors License Law for the U &
0 0 following reason.(Section 7Q!1.5.Business and Pefesion Code:Any city or county
E00
m which minues•permit to construct,alter.improve,demolish,or repair any avucwm [/ \• hsC�
prior in its issuance,also requires dm applicant for such Permit o Ole a signed staumem
that he is licensed pursuant lathe provisions of the Conmemis Crane Law(Chapter 9 Sq.Ft,Floor Area Valuation
ae�0 (commencing with Section 7")of Division 3 of the B usiness and Professions Code)or
i $ that he is exempt thamfmm and the thea for than alleged exemption.My violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 2VT# L@I*er0 0 Occupancy Type
net mom Nan fin hundred doll.(5500).
❑L as newerk.Bre pmpeny,tar is employee with wags n Nei((Sec.
compensation,
will do the work.and Ne swarm is nor mreoded or dreads not a(sec.Toa.Business
and property
bas Cade:The sonlacwn.and
law does not apply a an owner is Required IHSpeC[lOn$
Own eny who builds i improve thereon.and who doessuch work himselfor his
however.the Wipmvidcd pom suchimpmwmemavanmyearMcdmpledsedforsale.If,
n.the ower-
buwevenNeWildicbunmpnw em,oult didnot year ofimproeforpurpose of
builder will have tW W=den of proving Na W did not Wild or improve for purpose of
sa
1,m owner of Ne proany,am exclusively contracting with licensed commairs to _
c tract IW pmjett(See.7tk4,Busineu and Profession Code:)The Conuuwh Li
tecta law does oat apply tom owner of pmpcny who Wilds or improves Nemon.and
who contracts for such projects with a conuano(s)liarued pursuant in IM Continuities
License Law.
❑tem exempt un //r S�ec. B A P C for Nis mazon
;'VOL a¢
WORKU 5 COMPENSATION DECTION
I hereby affirm under penatyof Injury rota the following dalaations:
have and will maintain aCcr ificam of Conunno self-inum for Worker'sCumpen-
rn,az pmvidcd for by Section 37M of the tabor Code,for the perfmmaue of Ne
work for which this permit is issued.
0 1 have and will maintain Worker's Compcnamon Inu(ana,as required by Section --
37W of Ne labor Code,for the performance of Ne work for which this permit is issued.
My Workers Compensation hommnce carrier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF ExEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bo completed if the permit is forone hundred dnllaa($100)
or less.)
1 anifv Not in the perfam mance of the work for which this Permit is issued,I shall not
employ any permn in any mmocr so az to become subject a be Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject in the Worker's Compensation provisions of the labor Code,you must
wJO foorwith comply with such provision or Nis Permit shall W deemed mwud.
'Z'N CONSTRUCTION LENDING AGENCY
[— I hereby affirm don Here is a constactinn lending agency for IW performance of
(Yi the work for which this pnmil is issued(Sec.3097,Civ.C.)
Q Lender's Name
=Z Lcnderi Address
U 0 1 cenify,that I bare mad this application and sum that the above information is
Lt F co=ma I agree to comply with all city and county ondinenecs and sum laws=dating in
O V building construction,and hereby auNorim mpresenuti i of our city to enter upon the
C27 above-mentioned Property for inspection purposes.
F6. (We)agree to saw,indemnify and keep hornless the,City of Cupenino against
rn liabilities.judgments,costs and expertness which may in any way same against said City
V Z in consequence of the granting of this Permit.
APPLICANT UNDERSTAND VAN WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU .REGUL TIONS.
Ja
10 y Re-roofs
sign r pplicaovcomsmam ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
MWI capplicant or future Wilding Occupant store or handle huallous mrial
as defined by Nc Cupertino Municipal Code.Chapter 9.13,and the Hcahh and Safety
Code,seD mi 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
mi Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,1 agree to remove
't ha'Jardnn air conuminami u dcrined by the Bay Area Air Quality Management all new materials for inspection.
Dict?
❑Yes _®Nu p
Ihawmad Ne humdousmamdalsaqu wdm 54.I u Chapmol andiflhc wihong �Vv
nu Health&renty an.Section 25N154 myrand7553a,l understande Oifdm Wilding Aof &lica
docs oat cwm huc haw a tenant Nmit is my msprnibililY a mEfy e,occupant nI Nc
m memswbkh *4.L brwiu1!1! ofaCcotifcamofOce ancg "• ignature f�7Tit 1�?[e
\.WY /! 3a o�c
neturauthari'rmJage „e All roof coverings to be Clas "or better