04060188 CITY OF CUPERTINO � �A
BUILDING DIVISION PERMIT CONTRACT,QRnINFORMATION --
BUILDING ADDRESS: PERMIT NCO 4 0 6 0 18 8
ROBERT GRISWOLD
OWNER'S NAME: PERMIT ISSUE DATE
1361 ASTER LANE 06 22 2004
E: SANITARY NO, CONTROL NO.
ARCHIT=,ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
aOo LICENSED CON'IRACTOR'S DECLARATION
w I bereby affirm that 1 am licensed under provisions of Chapter 9(commencing .lob DOSCIIp[IooOlyyNsssaaa���...TW
I'� II /� (1 rrr���
W with Section 7IXp)of Divisian]of the Business uW Profrssinv Code.and myliccvcis n / jgl D�, II //\\ II
in tWWl toryroee and ter �. J'yga--Z LADNSCAPE, BBQ W GA$r ARBO a-t}}'`t`Wi7}iy('y'�;,\\111L�S
S a? LieeTsrCis Lic.N —�y�—a� DECa/s L
n t£- Uxm ARCHIIELTS L IGY/ /�GYA 4V LOU 1
1 un rstand my plans shall W use]u public records
Dau
ta Licensed Professional
iOs OWNER-BUILDER DECLARATION p //��
00 I hereby affirm that 11. ,Busin from the Conuamoo :Anyc Law for tk B p ® It// v
o O (allowing reamn.section RIJ o Bumps and Professions Code:Any city or corny WN�r [,b1Wt.fz^f
3:00
3 K which requires a permit to cnmlrun,shot,improve,demolish.or repair any structure
Fii prior to its issuarec,also requires the applicanlfor such permit to file a signed stammenl
gInti he is license]P...out.the provisions oftk cmussicmrs U..Los Chapter Sq.FL Floor Area Valuation
C (commencing with Section 7")of Division J of the Business and Professions Code)or
ie F F that W is exempt therefrom and Inc bass for the alleged exemption.Any violation of
Soldon 7031.5 by M applicant for is permit subjc.the applicant o a civil penalty of tATN
not mart thm fere hundred dollars(55 L a Occupancy Type
do
side theirny,nmymintended wirhwagautheirmle compenssnces
will Pr fework,and the swarmsenot intended Law
deffrond for sola(Sec.to aa, wner of
and Professions Code:The Cononctor's License Law Goes not apply Ire rt owner of Required Inspections
pmpenywho builds i improt such improvements
rove who aresahrchwork himselforllwugh his
ownemployee,provided Natsuchimproold wit arene year fc mpletiod forsdeco e.If,
-
huilder Nebuilding
ru improvement issoldwithinone year ofcompletion,theowner-
builder will have the Wrden of Proving Nal k did not Wild or improve for puryose of
sats.).
❑1,as owner of the properly,am exclusively contracting with licensed Contractors to
conswct the project(Sec.704d,Business and Profta4ons Code:)The Conbactols U.
canis Law data not pply to an owner of property who Wilds or improves deremn,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
L' w.
1 am exempt under see. ,B N:P C for this rcuon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations: _
have and will maintain a Certificate o(Consenuo self-insure for Worker's Compcm
inown,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which this permit is issued.
1 have and will maintain Workefs Compensation Insurance,as required by Section
]700 of the Labor Code,for the peifarmantt of Ne wmrk for which this permit is issued.
My Workcfs Compensarian lnwnme attire ey numkr art: —
PoI' N
URTIFICATEOFE%EMPI'I NFROM WORKERS'
COMPENSATION NSURANCE
(This section need not kcomplemd Box,permit is formic hundred dollars(5100)
nr less)
1 eerily thm in the Performance mf the wick for which this permit is issued,I shall not
employany person in an n nqw tors tree mb'ec Wo rkerecompeosauon
IpwaCali ra.
Applicant �
N: 1
ETO APP A L Al making this Ceniftcale of Exemption,you should
e esubject 0 the Worker's Compensation provisions of the Labor Code,you most
.,O f ith comply with such provisions or Nis pohnotshall k deemed revoked.
Z"n CONSTRUCTION LENDING AGENCY
IhenhymBrm that then is aconsuuclinn lending agency for Ne performance of
ori the work for which this permit is issued(Sec.W.Co.C.)
6W.Q lenders Name
.7 Z Lender's Address
U 0 1 Certify Net 1 have rad this application and state that the aW ve information s
W E-m correct 1 agree to comply with all city and county onlinances and sonic laws relating to
DUbuilding construction,and hereby authorize nepes
renmiM of this city to enter upon the
W akvemenuonadgm property for indirection purwwhich ms.
C (We)agree to save.indemnify and keep harmless the City of Cupertino against
N inCoitieuence of
gestsandof this expenses which may in any way attrvc against said City
U inConsequencethe granting of this permit.
^' APPLICA UN E3S!$NOS AND WILL COMPLY WITHL NON-POINT Issued by: Dale
IA
SOURC G AT7ONd.
_ ?' Re-roofs
hg uraofAppltaHAZARDOUSMATERIAlSDISCLOSURE Dam Type of Roof
Will the applicant W future Wilding occupant some or handle hanNous material
as de0ned by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
GOJC,SecYa tion 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fuwm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
U 0.
1 lei rdous air contaminants v declined by the Bay Arta Air Quality Managemet, all new materials for inspection.
0 Yea
1 neve read the hvardmrsmamrias requirements under Chapmr 6.95 of the Califor-
nia Fkalth&SafctyCodc,Sections 23N15,355JJ end 353Js.1 understand Jwifthc Willing
it rpt CYr�r�r�r�nJy aMyyp+��eee7tF��an4 that Il es my nsponsibiliry to notify JC eximpNt or the
YfmymM1s wti rr{u16dm pdorwissuance ofaC 'fmatc of Oca?nCY fj Signature of Applicant Date
Do.,ormitim .'em Dam All roof coverings to be Class"B"or better