05080269 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC"TnR INFORMATION .
BUILDING ADDRESS: GRANT & JUDITH LANGE PERMITNO.05080269
0881 BARRAN A DR
R'S NAME: PERMIT ISSUE DATE
GRANT & JUDITH LANGE 05
E: SANITARY NO. CONTROL NO.
ARCHITECBINGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ups LICENSED CONTRACTOR'S DECLARATION Job Description
tit FF 1 Micky affirm Net 1 am licensed under provisions of Chapter 9(commencing
�ir`$ with Section 7000)afDivision 3ofthe Business arrd ProfessionsCade.and my license is
in full Come and effect DEMO (E) HOUSE
j y�Z License Class Lic.
nor Dam Contranor
ARCHITECTS DECLARATION
Sa < I understand my plans shall M used as public recards 7' l
Oats /
s a G Littnmd Pmfcssional
ams OWNEon..ILOER DECLARATION
Conti ON 7
1 hereby affirm 00 I I. exempt from Be Contractor's License Law for the
o o following TEon.(Sect1Un](DCS.Buiin[a5 ind PN(LSV ON CndC:Any Cily ar[aUnry
K m which requires a permit to construct,alter,improve,dcmoliih,or repair any stsetum $2500
yai prior m its issuantre,also rrquims Be.pplieanl for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractors LiccnscLaw(Chapter 9 Sq.Ft. Floor Area Valuation
y (commencing with Section 7")of Division 3 of the Business and Professions COO)or
i $ Nat he is emmpl Ihcrefrom and dw basis for dm alleged eaemption.Any violadon of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of r Occupancy Type
not more Nan five hundred dollars(5500).
1,w owner of the pmpeny,or my employees with wags as their sole compensation,
will do Be work and the structure u notinwndcd uroRered forsafe(Sec.7044,Business
and Professions Code:The Contactors Liatue Law dao ant apply in an owner of Required Inspections
properly who builds or improves thereon,and whodoes such work himself or through his
own employees,provided Our such improvements are not intended oroRemd forsale.If.
howcvcr,the building or improvement is sold within one year of completion,Ne owner-
builder will have thee,Widen of proving mat M did not Wild or improve for purpsc of
sae.).
�1 I.as owner of Ne property,am exclusively contracting with licensed contnewas in
�lh met the project(Sec.7004,Business and ProRssions Code:)The Contractors Li-
case law dos not apply to an owner of properly who Wilds or improves thereon,and
who contracts for such projects with a conummr(s)licensed pursuant to the Contractor's
License Law.
❑1am ssem t under Sec. B k P C for this¢awn
�I.,0.r t ,� Data — —
CER M A ONp LARATION
1 Mreby aim under pcnahy of perjury n Mate the following declarations: -
aw and will maintain a Cenificam of Consent to self-insure,for Worker's Compen-
on,as provided for by Section 37W of the Labor Code,for me perfo mance of the
work far which this permit is issued.
I bars and will maintain Workers Compensation Insurance,as remained by Section
3]00 of Bc labor Code,far the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number one:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(This section need not be completed if IM Permit is for one hundred dollars($100)
tor less.)
1 certify mm in Bc performance of tM work for which this permit 0 issued,l shat)not
employ any Person nc as ie, me sub' mthe Workess'Compcnsation
Laws of Calif.
ApPlicam 1.
NOTICE TO AP CANT:IL after making firis Cenifcaw of itmaninion,you aibcZ
become subject in the Worker's Compcnsarion provisions of the IaMr Coo,you mum
.JO forthwith comply with such provisions or this permit shall M deemed evoked.
Z "r CONSTRUCTION LENDING AGENCY
[—�� Ihereby from 0.,Here iso connotation lendin,.,ne,for the parfonnanve of
5the work for which this Permit is issued(Sec.3VD.CO.C.)
W Q Lender's Name
IZ Lender's Address
U O 1 cenify that 1 have read this application and stat,Om the mors information is
D. correct.1 agree to comply with all city aml county ordinances and slow laws relating no
O V Wilding construction.and hereby authorise reprosentetisys ofthis city no enter upon rhe
W above-mentioned imperil,for inspection purposes.
(W,)agree to save,indemnify and keep harmless tM City of Cupertino against
o-Fi faA Iiabilides,ludgments.costs and oxpcnses which may in any way accfue against said City
C..1 ZAPPL CANT=UNDERSTANDS Athis
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
isoEGULATION . Re-roofs
mo(Applicam/ ontnao Dam
HAZARDOUSMATERIA DISCLOSURE Type of Roof
Will Ne applicant or future building Occupantstow or handle hazardous material
d by the Cupenino Municipal Code,Chapter 9.12,and tM Health and Safety
ction 25532(x7? All roofs shall be inspected prior to any roofing material being installed.
C Ycs �NuWin Bc applicant or futurt banding occmpant tax=wipm=rat ar dem,es whim If a roof is installed without first obtaining an inspection,I agree to remove
nwous air conminanu as IkOned by the Bay Area Air Quality Management all new materials for inspection.
❑Ycs No
1 have mad Ne minumms,materials requirements under Chapter 6.95 of NeCalifor-
ma Health 6 Safety Cade,Sections 2M5,25533 and 25534.1 understand Bat if th,Wilding
dos not curendy hove a tenant Nat itis my ropmsihility m notily the oceupmt of Be
re wIt It tM w r raamotlucdagent Date Ipdor tett aCcnlficamafOccupancy. Signature of Applicant Date
All roof coverings to be Class "B"or better