05110005 CITYOFCUPERTINO 7777 79777 �eHr
BUILDING DIVISION PERMIT ` CCINTRA �"1Y�R�[Nl)RMA1U1�1�'
BUILDING ADDRESS: PERMIT No.0 5110 0 0 5
AIMHART CT
OWNER'S NAME: PERMIT ISSUE DATE
FRED CONKLIN 01/05/2006
JE: SANITARY NO. CONTROL NO.
AR CHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo
LICENSED CONTRACTDWS DECLARATION Job Description
U I barely af0rm Net 1 am licowd under provision of Chapter 9(commencing
with Section 7M)of Division 3af the Busies arW Profwlnn Code,and my licew Is
AZ` inm11folaandefrem SFDWL-2 STORY-3166 ' LIVING
uanre°"` Lle.t GARAGE-462 '
et„ Dam CSDECr
S ARCHITECTS DECLARATION
1 understand my phos.hall be used u public records
5au
C Licensed Profwional
OWNER-BUILDER DECLARATION
I hereby.(Sero on I a1.exempt from the Commerce,oLicense Amy c law for the
i.pO following reason.($codon?arsonist,items.
vefwioes .a Any city or county
$� which requires•permit m commcL alar.Improve.demnitsh,or repair any swmure
Prior b its iuuance.As.mquims the applicant for such permit to film x.ignol summem
££i< that M u liconcd pursuant to the pmovisian of the Connector's U..Law(Chapter 9 Sq.Ft. Floor Area Val 1
Y~� (commenring with Section 70M)of D ion Sof Ne Businwend Professions Code)or
tNt M u eawPt terefmm and Me but for the alleged ex mption.Any violatlan of
Section 7031.5 by any applicant for a permit subjects the applicants m a civil penalty of APN Number Occupancy Type
an more Men five hundred dollars(M). 37537069 . 00
❑I.u owns of di Property,m my emplayaa with waga u M,b sats compensation.
Business
and Protection;Cock:c�nK CCo�a:at,intended��morias,simpate ly to a' of Required Inspections
property who be ilds or improves thereon.and who dots such work himsalf or through his
awn employes,provided thatsuch improvements w not intended orofferal for sale If,
however,the building or improvement is amid within am year of completion.the Owner.
Wilda will have the burden of proving that M did not build car improve for purpose of
sak.).
eJ 1,as owner of tic property.am exclusively contracting with Ilttwd eomeaeun u
colifu sa the pmject(Sec.7010,Bustnw aW Pmfestan Code:)Tom Centimeter's U-
cow law does not Apply m an owner of property who Milds or improves thereon.and,
who conu0ma fee such projects with a coneractaNs)licensed punuset m the ConuacmM1
Llano Law.
❑tem exempt notes Sea r B&Fcfa this won
r� i!/C6yG, '4i'l/Li Dam /
WORKER'S COMPENSATION DECLARATION
I hereby of irm under penalty of perjury aro of the following declaration:
I ham and will maintain a CeNfiamafCommnito salf-loom for Warke6Cmnpen-
ullan.u Provided for by Section 3700 of the Taber Cade,for the performance of On
wok for which this permit is Issued.
❑1 hoc and will maintain Worker's Compensation Insurance,u required by Section
3700 of the taper Cade,for the performance of the work for which this permit la loved.
My Worker's Compensation Msunnce carder and Policy number am:
Carrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TIM,section need not M completed Ifflue permit is forms,hundred dollaa(S10()
or leu.)
1 certify Not In the performance of the work for which this penult is issued,I shall not
employ any person in any ma SW�becomc mbjecua Me Worken'Compasaton .
Lawaof California,Dam G0 --, ZJ,�Z�—
NOTIApmC rat
NOTICE TO APPLICANT:ff,Com making this previsions
n s of of Labor Exemption,you should
become subject comp m tic Workere Compensation provtsioa of the Labor Cnde,you must
wJ,'� forthwith comply with such previsions or this Permit shall be dcomcd mvak,d.
z O CONSTRUCTION LENDING AGENCY
[-v 1 hereby affirm that there lir construction lending agency for the isaformeme or
ai h7 the work for which this permit is issued(Sec.3097,Civ,C.)
W�Q Iandces Name
.7 z LendasAddrw
U Q 1 aNfy that I have mad this application and sum the the above Information b
Uy Fcorrect.I agree to comply with all city and county ordinances and sum laws relating to
0 building construction,and hereby mNorim reprwntniwa or this city to enter upon the
W ahovcmemianW PMPeny for IMPUMM purpoea
(We)&gma to an.indemnify and keep limitations than City of eupertino against
gen liabRides,judgmcnts,costs and expenses which may In any way ammo against said City
t.) in cov¢quace of the granting of this permit. /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /— 7 G`
SOURCRE ATIONS.
,r�r� f�oG' Re-roofs Q
Siyutu of ApplianVConuaetor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or future building asupuuure or huWle harardaaf msmtal
ss dentcd by the Cupertino Municipal Cada CMpmr 9.1x.and the HeHtb red Safely
code7.qul.'.' nxrax
[]Y.7ss3x(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
sun the.applicant car future building sera nL w If a roof is installed without first obtaining an inspection,I agree to remove
1 PP g pa ea Air Q l or Mann which
avrdnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
m7
❑Yes (V-
I havemad the husrdoes matedals mquimme nu undo r CMpmr 6.95 of toe Calla.
aWh&Safety Coda Ser.Ww75505.x5533mu1x5534.1 mhdematW talftc building
est currently have a mnant.that It u my respenlhility m netify the acouput of the
wnic aabemm plasm Wauco ancenirmam aracupamy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner ora thntimed Sent Dam C,