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CITY OF CUPERTINO
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BUILDING DIVISION PERAUT
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BUILDING ADDRESS:
PERMIT NO.
101.66 BARBARA LN
TBD — TO BE DETERMINED
08070145
NET'S NAME:
PERMIT ISSUE DATE
08/13/2008
"ONE:
SANITARY NO. CONTROL NO.
ARCHttE(.T/FU4GINEER:
BUILDING PERMIT INFO
BLDG ELECT PLT - MOECH
LICENSED CONTRACIDR'S DECLARATION
Job Description
Web, affirm Nat 1 am Ihsnud under pmrisioru of Chapter 9 (commencing
with Section 100m.f DiAiom3orf Bush. and Proreesiom Cods. and my flaw is
ADD 66SQ LIVNG,STDYRM,BTH,MSTR BTH&
in full fade end effect
uet�0.as Le.#
PORCH(54SQ)AND RMDL KTCHN(200SQ)& BTH(50SQ)
ARCHITECTS DECLARATION
1 undessund my plans shall be used u public rtcoda
Licensed PmfeasionaI
OWNER -BUILDER DECLARATION
1 hereby affirm that I stn exempt from the Cmveeors License Law for the
i following mason. (Section 7M n 11.5, Business ad Professions Code: My city or county
_
which requires a permit to construct, shot, improve, demolish, or repair my suueum
! PH., it, its Lssua....lm requires the applicant for such permit to Ne a signed statement
W she Consumer's Limnse taw (Chapmo 9
Sq. Ft. Floor Area
Valuation
Nat W ie licensed pursuant the provisions of
$90000
1(momemingwithSection1000)efchrism3ofuseBusinessadproposals.Cede)er
that h is exempt therefrom and Ne basis for the alleged exemption. Any vlolatim aro
35912024.
Occupancy
Pane y Type
Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty ofNumber
not mart Nan fie Imndmd dollars (SM
0 1, a .,of she propert, or my employee with wages as Heir rule..,.ado..
Required Inspections
will do the work, and th atmcwn is not intended moffered for sale (Sec. 10U, Business
and Prfewom Code: The commetees License law does cot apply m an owner of
oroelfmtioWytbu
,
eel pang such impmemwt vex not intended o@red for We. If,
man that such
a
mid withinoneYouofmmpleGonNdowner-
tor, th or Impr m
however, the building aro
how
amofmomng
huddler will lure the burden of morning Nat W did cot build a impmto for purpose of
a
tale.}
V1, as owner of tin property, em emmeitoly contracting with licensed con0actma W
comtrcl the project (Sec. 1044. Business and Frfe1510. Code:) The Contractors Li -
come law does not apply m an owner of property who builds or impress thereons and.
was moment rat such pmjeas with amnuanorca) licensed penman W the Convenors
Lim. law.
0 lam exempt
DECLARATION
I hereby air= under penalty of pejury orc of the following declamions:
❑ I hato and will maintain a Certificate ofConsent m self -insure fm Worhrs Compton-
Wisn, as provided for by Section 3100 of the labor Code. for Ne performance of the
work for which Nis permit is issued.
0 1 have road will maintain Wormer Compensation Imuran¢, u required by Section
3700.f the tabor Code. for the perfa manceof the, work for which this permit is issued
My Worker. Compensation I.unnm carrier and Policy number vex:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
mcis seder need not W completed lithe permit Is from bunNeddoBars (SIM)
or leu.)
1 cutin dust in the pnfmmasm of the work rot which this permit is Wood. I andl'nor
employ any person in my ..r;= subject 10 uewmaen'Compensail
laws of
of Eacmption, you should
became subject be the WontrYs Compensation provisions of the tabor Code- you must
' foMwiN comply with such proviso. or this permit shall W counted revoked.
CTION LENDING AGENCY
j Cas
ft. agency for Nc perfomaras of
herby I hbarm y aldm ueu s led
(Sm. 09 . Cov.
' she wort for which Nu peril u ivucd (Sm. 7091, Civ. CU
Lenders Name
Landers Addmas
1 anifY that 1 into read Ws uppliessm. and mute Net the We informed.. is
' correct. l agree m comply wish JI city ad county elinanw and most laws retain, W
Wilding conswcu m. and hereby auWoda mpvemvim of Nis city m aur, upon f
alone -mentioned propeny for inspection purposes
(We) agree to save. indemnify and keep harmless the City of Cupertino against
j Iimilises judgments. costs and expere which may in any way erne almost said City
in consequence or the purr, of the permit
' APPLICANT UNDERSTANDS AptD WILL COMPLY WITH ALL NON -POINT
SOURCE RLEG/
DISCLOSURE
Type of Roof
Will tic applicant or future building occupant von or handle hamdom materia
u defined by th Cupertino Municipal Cade. Chapter 9.13, and the Health and Safety
ode. seldom zss3z(g1 ��
El Y. tgNo
All roofs shall be inspected nor to an roofing material beim
P P Y g g installed,
Will me applicant or future Wilding nesePant use egwpmem or device which
If a roof is installed without first obtaining an inspection, I agree to remove
emit haradosa all coornimnu as dertml by Ne Bay Ana Al, Quality Management
all new materials for inspection.
District?
0Y. Nu
I have read the harmless materials ro ubsomms under Chapter G95 of the Califs.
ria Hcal" Safety Cade. Sado. 25505.25537 and 25534.1 undimmed thin ifde Wilding
dna not curendy hoe a aunt usv it u my responsibility be miry Nc asupml of de
regairemont,
Date