04070102 CITY OF CUPERTINO
BUILDING DIVISION PERMIT z,C�NTk1M:d "F�''MR61tMATION ;z
BUILDING ADDRESS: MARY TRAN PERMIT ND04070IO2
AV
OWNER'S NAME: PERMIT ISSUE DATE
MARY TRAN
E:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGEIFLT PLUMB MECH
0 0 0 0
ti0o LICENSED C'ONTRACTOR'S DECLARATION JobDescri tion
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
withection 7")of Division 3 of We Business and Profcssioru Code,and my license is
�'n Sin full funeAM West. REVISION--TRUSS . SUBMITTALS
j 4 License ClassLk,a
^f-, Dam COarmtr NO NEW PERMIT ISSUED/ ORIG. #03090227
i ARCHR CTS DECLARATION
Ky>W U 1 understand my plans shall W need as public records
Licensed Professional
S OWNER-BUILDER DECLARATION
.�i I I hereby aRrm Nat 1 am exempt form We Commelor's License Law for the
O O following mason.(Section 703 L5,Business and professions Code:Any city or county
m which requires a permit to e..L alcor,impresser demolish.ar mpsir any structure
prior in its issuance,also requiam de,applicant for such permit to file a signed stammenr
Wm he is licensed pursuant to the provisions of the Connector's License,Law(Chapter 9 Sq.Ft. Floor Area ValuatiT,15
p1S (commencing wish Section 7o W)of Division 3 of the Susin=and Prefosssinm Cade)or '7
Wet W Is..,I thertfmm and she basis for the alleged exmpma.Any violation of
Section 7031.5 by arty applicant for a permit subjects We applicant at a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500). ,
01.uowner of Ute propeny,mmy employees wish wagesu Weir sale mmpervadon, 37512029 . 00 v.
will an We work and We structure isnot intended or offered lot(Sec.7066,Business
And Professions Code:The Contractor's License law does not apply to an owner of Required Inspections
property who Milds or improve Warton,and who docs such work himself or through his
own employes,provided Our such improwmtam am not intended or offered for We.IL
however.We building or improvement is mid within one year of completion.We owner-
builder will have We Wohm of proving Wer he did am Mild or improv,for propose of
s)1e.).
I,as owner of We property.am exclusively contracting with licensed conuacmrs to
c nsvuct We pmject(Sec.7(44an2ue)
,Business d Proions CadThe Convector's Li- .
ccnx Law dors not apply to an owner of propeny who Milds or improves thereon.and,
�,Mconuactsho for each projects with a contracmr(s)licensed pursuant tu We Coman o's
en w.
ex�emppt�under
�Sec.
..,. B&P C for this rasion
er 1`v wl WO 1/1/�KRt. Data
TION .
( WO KER'S COMPENSATION DECLARATION
1 hereby affirm under perWty of perjury one of do following declarations:
l have and will maintain a Cartifica,of Consent to self-insure for Worker's Compen- '
.tion,as provided far by Section 3700 of We Utter Cade,for IN peRormance of she
I,for which this permit is issued.
❑I ban and will maintain Worker's Compensation Insurance,as required by Section
37W of We labor Code,for the pnfarmancc of We work for which this permit is issued.
My Workces Comm don man.cornu and Policy number are:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
tutu section need nut M completed Bthe permit Is foronc hundred dollars(SI00)
or leu.)
I cattily War in We performance of the wart for which this Permit u issued.I shall not
employ any Nixon zany manner m az to tocomc subject to the Wnkcrs'Compenation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Wu Ccnificate of Exemption,you should
become subject 10 We Worker's Compensation provisions of We Labor Cook,you must
.JO forthwith comply with such provisions or this Permit shall 4 deemed revoked.
'Z,..r''"" CONSTRUCTION LENDING AGENCY
.�.F IherehY affirm Oat Nem is a communion lending agency for We
Performance of
a We work for which Wu permit'u issued(Sec.3097,Civ.G)
QLender's Name
� z ULcadcr's Address
U C) 1 cenify that I have read this application and state Wm We stove information Is
La. r cormca 1 agree As comply wit all city and county oNinances and a om lave relating to
0U building construction,and hereby aurhorim reprexnurins of this city to enter upon We
r M above-mentioned property for impaction purposes.
F (We)agree m ave,indemnify and keep harmless the City of Cup,nino agaisut' jj liabilities,judgments,costs and expenses which may in any way accme against aid City
Uz in conxquenet ofW .,ting of this permit.
"-' APPLICANT U STANDS AND WILL COMPLY WITH ALL NON-POINT sued by: Date
SOURCE REG 0
e-roofs
Sienatu fAppli< _HAZARDOUS MATERIALS DISCLOSURE rorDate Type of Roof
Will the applicam or fururcWilding uxupem nam ar handle hapardom mated.]
As defined by the Cupertino MWO61.1 Code.Chapter 9.12,and Wt Health and Safety
Code.SecEldon 255320)?Y. I�TNO��` ��� All roofs shall be inspected prior to any roofing material being installed.
Will Inc Applicant or future building aces ant use, If a roof is installed without first obtainingan inspection,I agree to remove
pp i p quip u or Mara which P g
u hmamnus air contemivnu u defined by the Bay Area Air Quality Management all new materials for inspection.
vistdrR P
DYca
I have mad We btrard0u Iodais requirements under Chapter 6.95oftheCalifor-
nia Health&Saf,tyCode.Seeuom 25505.35533 and 75534.1 unchm and that if the Wilding
dots nor camchtly he a unx4 that it u my responsibility b noury do occupant of We
mquirernenl. h aatkmetpr;orwinumme.f.cerdfieamafae O Signature of Applicant Date
er ar amino < .gen, "MaAll roof coverings to be Class "B"or better