08050221 BUILDING DIVISION PERMIT Cili?PSR'AGTORI1k'OLLMATION
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BUILDING ADDRESS: PERMIT NO.
8:55 BETIA N AVE BD - TO BE DETERMINED 08050221
OWNER'S NAME: PERMIT ISSUE DATE
nJA Jr. 07/24/2008
ONE: SANITARY NO, CONTROL NO.
ARCHTTECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0 0 0
woo LICENSED CONmead under
DECLARATION Job Description
lug 1 hmbY,form NSI 1 am Iiconsed under ProvWons of CNptor 9(commcrcini p
_ withSadon7gR0afDivision3oftWBusimeandProfessionCode,aadmyliecaets DD(508 . 45SQ) PRC H@LOB BY, BEDRM#I,BDRM#2,RMDL(225)
in full fora sad arrest
�qz Licenmams Lic.R VRM,MBDRM, KTCHN, DNING& ADD WIN; INCLD STRUCTURAL
.r Date Comraam
qq ARCHrIECrS DECORATION
W U 1 undanamd my PlanN
s all W used u Public research
6
Is
c� Licensed Profe,sioW
OWNER-BUILDER DECLARATION
y 1 hereby affirm Nn i am exempt from tic Conuractoes License Law for the
i 0 o following mason.(Section 7031.5,Business and Profession,CWe:Any city or county
a g� which requires a Permit m construct,shim,improve,demolish,or mpur my stmeture
'Iii prior W its issuance.alw requires the applicant for such Permit eo file a signed stament
p�o
that W is licensed Pursuant W the provisions of the Contactors Liame Law(chapter 9 Sq.Ft. Floor AreaValuation
es
y @ (commencing with Section 7")of Division 3 of the B usins and Profrsedom Cad $e)or 70000
y Net he is exempt therefrom and the ball for than alleged eamption.Any violation of
Section 7031.5 by my applicant fora Permit subjects the applicant in a civil penalty of N Number Occupancy
amtfume Nan five hundred dallam(SSOOL 6927021 . WT'Pe
❑I,aewner of the popmty,mmy wployaa wish wgesaduv sole compenaeon.
will do the work,and the muchme is not intended or offered for sue(Soc.7061.Eua ms
and Professions Cade,'Th Contsaeroh I iceue law does not apply to an awar of Required Inspections
pm0e.y when builNain,prom Nmtmmaad wW dmsuchvmkhimselfmthough his
Own employes,provided that such improvemmo me not Intended Moamar!fmsals.H.
hwems.the aiding or improvematt is said want.one year of mmpteume.dr,owner-
builder will have the burden of proving that W did me WfW or improve for puryox of
aleJ.
1.as owner M the property.am exclusively contracting with Renewed conwseoo in ..
convect she Project(Sec.7066.Busims and Professions Code:)The Conmmmr'.B-
ane law does not apply m an own,of property who builds or improves the mon,and,
who contracts For such Projects with a contractor(s)licensed pm,nsnt at the Contractor's
Luc..Law.
❑Imememptundersa ,B&PCforniamamn
wrca I...l�.\fes ) Data 71w 0�
WORKER'S COMPENSATION DECLARATION
I hereby Loom under penalty of perjury ane of the following dnelarmions:
❑I haw end will munWn a Cndfiauof Coamnt m self-in,um for Worker's Compere -
andon.Is provided for by Section 3700.(the labor Code.fm use Performance of the
work for which this Permit is isstrd
❑1 have and will maintain Worlu ,Compensation Inmuance.as acquired by section
3700 ofthe lahmr Cods.for the performanaorthe wort for which this Permit isfamed .
MY Worker's Cnmpemauon Inaaance artier and Policy number art: ..
Carrie. Policy No.:
CERTIFICATE OF EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs sectlm need not becomFlcud Rtlu permit is fmonc hundred dolun($100)
or leu)
1 caW h not in the Perfmm.nee of Ne work far which this Permit is Issued.I Nall not '
employ my person in any mamser an Is W became subject to the Wofken'Compenandon
Laws of Cmifomia.Date
Applicant �tL+r- g
NOTICE TO APPLICANT:If,stem along Nu Certificate of Faemption,you Mould
become subject m the Workel,Campewdon Provisions of Nc labor Cede,you most
.Jz foMwiN comPlY with such Proniuns or Nis permit shut W dnemnd revoked.
ZO cc)ft
LENDING AGENCY
(~ I barely affirm that Nem u a corwuction leading agency far ft Perfine.a
C > site work for which this Permit I,issued(See.3097,Civ.C)
plender's Name '
D z lrnEer's Add.
U O 1 eestify that 1 have read this application and seats Nat the move ofmrma.I,
U. F correct-I agma In amply with ml City and county ominaraes and sou laws relating to
C) Wilding construction.anal hereby mNoum aetnuenuuvs of Nu city to enter open the
U ,Ww-menuoned Property for imPeNen whit ms
tom„y (Wen)ague to ave,indemnify and keep harmleas the City of Cupertino against
U Z incOius,jndc Of the
and nspemeswhteh mai in any way come against said City
U z in cornegnenea of the ganung of this permit-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT- Issued by: Date
SOURCEREGULATIONS.
__T: 7#4 Re-roofs
Sugnaere of ApplicanUConuuor acData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appfiant or future building oaupeal more or Mad[,handan,material
as daRrcM by Irk Cu""Muueipal Code,Cmprcr 9.13,and the Hand,and Wary
V*
Section zss3zto7 NN. All roofs shall be inspected prior to any roofing material being installed.
V*
Will ft applicant or footman Wiltling past use cgolpmem w dcNm whirl g P
If a roof is installed without first obtaining an inspection,I agree to remove
aav
mit
lb Tardnw ter conumimn�cs a.defined by the Bay Ams Air Quality Management all new materials for inspection.
DiRriOyes rL}Nu
I have read the harardtmsmamiabrequimmcnts underCMPar6.95af NI Califor-
nia Hanle!]&Suety COde,Sccuona M505.25533 ani 35534.1 understand sive ifdu Wilding
does not currency ham•tenant that it is my ornamentally W notify the occupant of the
mqubarmas whichmuRbcmatprior W issuance,of a ccnifoam of Occupancy. Signature Of Applicant Date
2u a
Ow.ermamumriaad.gane DOW All roof coverings to be Class'W'or better