03090227 CITY OF CUPERTINOa •'- , �,d.¢�,r'z a `
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,rc
BUILDING ADDRESS: PERMIT N003090227 -
OWNER'S NAME: PERMIT ISSUE DAM
MARY TRAN
,NE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
l� 0 0 0
=oo LICENSED CONTRACTOR'S DECLARATION
y m I hereby affirm that 1 am licensed under provisions of Chapter 9(ammcncing Job Description
<ZW wlNScc40n lIXMI)af DlvlaionJaf lne Butinetl Ltd PIOrCStinna Code.andmyli[cmc is
"oma
Liin full Ohne and effect' SFDWL-LIVING SPACE 1825 SQ FT
Znn Lomere Class c a
'a Data Cenwcmr GARAGE 417 SQ FT/PORCH 49 SQ FT
t- ARCHITECT'S DECLARATION
I understand my plans shall M used u public records ,
JyU
;aG Licensed Pmfcuinnel ��
x 3 OWNER-BUILDER DECLARATION e
0 0 1 Maso affirm that 11. exempt from the Commps Cos License Law for the
a O following meson.(cordon 8131.5,Business and improve,
de ens Cour:Any city S county
K m which its Usts a permit or enntt be mfea improve,h erstit 1 file
repent any mtuctac
'A pri0rm16 troit!e.alWmgoithe lM ippbrN(roe Such pnmilmccron ave alhNmenl
isc matMiauanYdpareaanlmmepmvitinnan(mrcnmerme•tueenaehw(cn,ptre9 Sq. Ft. Floor Area MAR
— Valuation
¢H (commencing with Swim ti
i Nat he is exempt therefrom and Ne basis for the alleged esemption.Any violation of C 275000
section 7031.5 by arty applicant for a permit subjeoa the applicant a.arnil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars($500). P Y YP.
l,umwner of the property,or my,mployru with wagesu their axle componation,
Mildolhawosk,mdtheawmum isnotimendedra.1frW fersah(See.7W.Busi. pt nae asn
and Professions Code:The Communities License Law does not apply to an owner of Require InspbcuonF
pmpen y who bun Ids or improv Nercon,and who dao such work himsel f or llmugh his
own employees,provided Nat such improvements are not intended mored formal,If,
however,the Wilding or improvement is Said within ma year of completion.She owar-
builder ,will have tbo human of proving that M did not Wild or improve for purpose of
sale.).
1,as owner of Ne property.am exclusively convecting with licensed conramom to
container the project(Sac.7014,Business and Profession Code:)The Contractors Li-
ecnu law docs not apply t0 an owner of properly who Wilda or improv tkmon,and
who contracts for such Imes
witha emntramor(s)licensed pursuant in the Contractors
License law.
Alam exempt n r cc. 1 B k P C for Nis mazer
Shvrne tram
WbI ATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Car ifeau of Criminal to r-insure for WmkersC.Par-
sation,u provided for by Section 37W of the labor Code,for Ne performance of the
work for which this beton is issued.
1 have and will maintain Workers Compensation Insurana,as required by Section
37W of the labor Code,for the performance of Ne work forwhich this permit is stand.
My Workers Combination Insurance earner and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This action need not M completed if tM permit B forma,hundred dollars(SIM)
or Max)
1 anify Na in use perfmma me of the work for which this permit is issued.I shall not
employ any Knoren in any manner m as at become subject to the Wortrrs'Compemation
Laws of California Use
Applicant
NOTICE TO APPLICANT:IL after making Our Certificate of Exemption.you should
become subject m the Worker's Compensation provisions of thin labor Code,you mum
.,z forthwith comply with such provisions ter Nis permit shall W domed revoked.
z O CONSfRUCfIONLENDING AGENCY
(-. Thereby arfrm Nat them is a construction lending agency for the performance of -'
lYthe work fur which this permit u distinct 30
nct( 97,Civ.C.)
W A Leader'a Name
6. finders Address
az
U Q 1 cenify that 1 have read this application and tau that the above information u
ly F
Correct.I agree to comply with all city and county eminences and ram laws alining to
0 C.7 building construction.and hereby authodae rcpreaenuuset of this city to now upon the
W above-(We) ra 1.ma.mrinsonfy and keep
1
(We)agrees,ave,indemnify end kap harmless the City or Cupertino against
Ft,tz nablliun,judgments,costs and expenses which may in any way accrue against aid City
V z, in eensegancc egnming of this permit.
^' APPLICANT DERNANDS AND WILL COMPLY WITH ALL N-POINT Issued by: Date
RCE A
Re-roofs
Signatur2lonA canrContracmr Mail I
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant slam or handle hazardous mausial
in defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cwr.Section 35533(a)^ All roofs shall be inspected prior to any roofing material being installed.
❑Ycs No
( Will thc applicant o Lure building occupant use equipment or davirm which 'If a roof is installed without first obtaining an inspection,I agree to remove
At� hazardous air contaminants u defined by the Bay Area Air Quality Management all new mat i s for inspection.
Du1rmL1
F1 Yes u
I have mol haamnus maarials reyuiremcna under Chapar6.95 mf the Caiifor- / O�
nu Health&Safety msec.secuem35N)5.35533am 53d.lun&rsu ifur Wilding
does mot cur a ate a fens. N it o my mapmnsibilky a notify N,acupan of 1h
r immen i m n or a issuance of a Ccrdficamo(0't� an.y. Signature of Applicant Date
mer a hodzcd agent DEM e All roof coverings to be Class "B"or better