04090103 CITY OF CUPEWFINO �"^° = � n^ '4 , "�%- •' "^ ' �'* ^«
BUILDING DIVISION PERMIT C,0NTRACTnR INFORMATION
BUILDING ADDRESS: ==SKOETTER & BREEDING I LTRMITN04090103
0455 BANDLEY DR
OWNER'S NAME: PERMIT ISSUE DATE
CHINESE CHURCH IN CHRIST 1960 THE ALAMEDA 420 10/18/2004
Is NE: SANITARY NO. CONTROL NO.
(408) 246-3691
ARCHITECI]ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
(� 0
Op LICENSED CONTRACTOR'S DECLARATION
U F 1 h rcby art rte Thal 1 am lmenxd%der pr+visions of Chapter 9(commencing Job Description
aw will9ee CCn'/UM))af Division3of the BY51 Profeadons Cole.andmyliccnxis.
^�„ tont anderfn<t. REVISION--ELIMI . 2 EXT. DRS . @ 112/113
4Sq3 Lmeseaazs Lie.a NO NEW PERMIT ISSUED/ ORIG. 404040178
HO Dam Contractor
mj
ARCHITECT'S DION
�nderslanJ my plans shall W used az pu Tic nrJs
;AU
OLicensed Professional
iv, OWNER BUILDER DECLARATION
<� I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following mason.(Section 7WIS.Business and Professions Cole:Any city or county
x m which requires a permit to construct,alter,improve,demolish,or repair any structure
prior o its issuance.also requires the applicant for such permit to File a simednatement
�O that be is licensed pursuan,tothe previsions Ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuatio 32
�C$ (commencing with Section 70001 of Division 3 of The Business and Professions Cents)it
_ that he is exempt therefrom and he basis for the alleged exemption.Any violation of
Seen..7031.5 by any applicant for ape.it subjects the applicant to a civil penalty of ApN Number
not mom man five hundred doll..ISM 32633102 . r 0 Occupancy Type
❑1,az owner or the f.,,t,or my employees with wages m their sole compensation.
will do the work,and me stuctum is not intended or offered forsale(Sec.7004,Businw
m
and Professions Code:The Conctori License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who docs such wart himself or through his
own employees,provided that such improvemena sue not inanded or offered for sale If.
however,the building or improvement is sold within one year Of completion,Ne owner
builder will have the burden of proving that he did not build or improve for purpose or
sale.).
I.as Owner of the progeny,am exclusively contracting with licensed contractors to O�
stmet the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves demon,and
who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sea --�Jy��� ��-a � B&P C for this reason
Owncr��� �Lffrl - `_Dam OL
AIL—VIRKER'S COMPENSATION DECLARATION
1 hereby affirm undcr penalty of perjury OM Of the following deelafatio¢
I hew onJ will maintain eCenifeac of Conant to self-inxum for Woher'u Cumpcn-
union.as provided for by Section 3700 of the Labor Cole,for Ne N60MA we of The
work for which this permit is issued,
❑1 have and will maintain Worker's Compensation Insurance,az mquimd by Section
3700 of the lariat Code,for the performance of the work for which this permit is issued.
My Workers Com penaation Insurance nater and Policy number are:
Carr Policy No.:
CERTIFIC COMPENSATION
ATION ON M WORKERS'
COMPENSATION 1lJS ANCE
(Dissecting need not W completed if the Permit is for one hundred dollars(Slat)
or les")
I sooty that in the performance of the work for which this Permit is issued,1 shall not
employ any person in any manner so az in become subject to the Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making his Cenilicac of Exemption,you should
become wniect to the Worker's Com pc union provisions of the labor Code.you must '
� z forthwith comply with such provisions orhis form itshall Wdeemed mvoked.
'ZO CONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a construction lending agency l or the perfurmanec of
:4 one work foe which his permit is issued(Sec.3D97,Civ.C.)
Lender's Name
= ,Z Lender's Address
V Q 1 eg ify our 1 have read his application nW sate Thal the above information is
L. F-' const.1 agree to comply with all city and county Ordinances and state laws relating to
pU building conswnion,and hereby authorize representatives of this city to enter upon the
shave-ms,judo d pmpeny for i expenses
pe hies purposes.
F G (We)agree m save,indemnify and keep harmless the City of Cupertino against
rq On cirtrquene of u.the granting
of this esmit. may in any way acerae against said sty
V z A APPLICANT
of UNDERSTANDS
of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da[
SOURCE REGUL TIONS.
oat fA pliwnV umraclor Dam Re-roofs y
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stare m handle haraNuus material
az def bed M1y the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cndc, [D Yea
25532(¢)? r�Np All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air conaminantvaz defined by the Bay Arca Air Quality Management all new materials for inspection.
4tolict, P
❑Yes b]No
1 have mad the hanw"us mzwrials mquimments undcr Chapwrl.95 of the Califgr
nia Health&Safety Cok,Scctinnt 25NI5,255JJ and 25534.1 undcrslanJ thatiftM WilJing
does On,currently hate a tenant,that it ii my msponsihility w noFily he tx'cupanl of thc
re"norm nawhich must I t issuance or a certificate,of Oce ey.
Signature of Applicant Date
caner ed agent All roof coverings to be Class "B"or better