04080203 77
CITY OF CUPERTINO `�"^' ` " "
BUILDING DIVISION PERMIT CON�TRAC�TORiINFORMATION.
BUILDING ADDRESS: PERMIT NOO 4 0 8 0 2 0 3
211 RTrPrPF.P C)AK ST
M'S NAME: PERMIT ISSUE DATE
ANDREW
NONE: SANITARY NO. CONTROL NO.
ARCHITEC lENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION lb Description
s C I M1cmby affirm
UZ00 Nat 1 am licensed under proWmo
v
u of Chapter 9(commencing
$ with Stttion70n0)ofDivision 3 of Ne Business and Profcssium Code.and my licenso is
<% in full force and effect.
Liz License Class Lica REMODEL--LIVING ROOM/BATH
nFn Date Contractor /
dry ARCHITECTS DECLARATION
,a IunticrstanJ my plans shall he used upublic records I�®
3r u qpa
''O Licensed Professional
g OWNER-BUILDER DECLARATION / ]'
iY 1 hereby affirm Nat I em exempt from the Cim rxaor's License Law far tM
00 following mason(Section 7031.5,Business and Profusions Code:Any city or county V 7005
vm which resolves a permit to ennamat,tiro,.improve,demolish,nr apair any shucum
prior m its issuance.also myuires the applicant for such Permit to rile a signed statement
Nat be is licensed pursuant toWeprovisions ofNoConuanur'sLicemeLaw(Chapter 9 Sq.Fl. Floor Area yycs��, Valuation
FVFG (commencing with Section 7")of Division 3 of the Business and Professions Cmle)tar L j-s + p
$
that he u exempt therefrom add time basis for the alleged exemption.Any violation of .{, y a R&!�'.`�
Section 7031.5 by ury applicant for.permit subjects Ne applicant to.civil penalty of 3 2 Ne10 0 meup3riq`'-T
not mart than five handled dollars(g500).
ype
❑1,as owner of Ne property,or my employees with wages im Neo sole compensation,
will do We work and We structoa is not intended proffered for sale(Sec.70x4,Business
and Professions Code:The Contractor's License Law does not apply to in owner of Required Inspections
property who builds or improve.thereon,and who dons ouch work himself or through his
own employees,provided Nat such improvements tie oat intended conferral forsale.If.
however,We building or improvement is sold within one year of completion.the owner.
builder will have We burden of proving Nat he did not build or improve fur purpose of
sato.).
1,as owner of We property,am exclusively convening w licensed contractors m
construct We project(See.701,1.Business and Professions C :)The Convacho
cense law Nrsnotapplymanownerafpmperry who Wil or improwtbamsm.and.
who conuactsfor such projects with a contr.ctor(0 liana ...110 Ne ComracmYs
License Law. z
l am exempt un TSec. .Bk PCfo Nisrt n
e Dam e( 9
WORKER'SCOM SATAON��DF.Cbt/RATION
1 hemby,a/fum ander pcnahY of perjury ones following doels nkma:
1 have and will maintain a Cenificateoconsenuo self-insure fm Worker's Compen-
sation,W provided for by Section 37M of We labor Code.for We Performance of We
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation li sunna,as requited by Section
311,f the labor Code.for We perfmmance of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number aa:
Career: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not WcomplemJ tribe Permit is foroachundrtd dollars(5100)
n less.)
1 certify that in We Performance of We work for which this Permit is issued.l shall not
employ any person in any...at.u to became subjttuo d¢Woders'Compenmtimi
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of We labor Code,you miss
.,z forthwith comply with such provisions or this Permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hemhy affirm that thele is a conavunion lending agency for We Performance of
G'
We work for which this pamnit is issued(Se:.3097,Civ.C.)
!1]Q Lender's Name
=z Lender's Addle..
U C) I certify that 1 have mad Nis application and sum Nat the above information is
f-' confect.1 agree to comply with all city and county ordinances and state laws rotating 0
0U building emiumleion,entl hereby admOrim repcienutivss Of Niscitymcnmrupnn Ne
}' ahovc-mcntiuncd property for inspection/Em"
G (We).gra to save,indemnify andss thc City of Cuertino against
lubilitiu.judgmcnts,costs and expenses nywayaccmeagainstseidCity
Uz memoreyucncc of c6ranting of Nis PerAPPLICANT DE ANDS ANO LY WITH ALL NON-POINT Issued by: Date
s0 ER ULA NS.
L u 2 Z' " Re-roofs
,$.at.. Ap,ImxdUCon mr au
H RIALS DISCLOS Type of Roof
__Wdl We applican Of future building occupant store or handle Intardous material
efncd by the Cupertino Mu icipaI Code.Chapter 9.12,and We Health and Safety
,eion2ss32(a)+ Na All roofs shall be inspected prior to any roofing material being installed.
will74 Nc applicant or future building occupant use cyuipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
omit W ardove air contaminants 11
defined by the Bay Ama Air Quality Managcmcm all new materials for inspection.
District?.
Yes Nu f
/l have mad the harar ous materials myui ems under Chapter 6.95 of Ne Califon
.to Health h Safety Code,Sections 25505,2553 42553,1.l undersunJ that lithe building
docs not cu dy hast a tenant.Nat it ism rtaponsibility to Imti�. l Nc
royal mane mnprinrtoi a ccofaccmfieaaoSignature of Applicant Date
..xdse All roof coverings to be Class"B"or better
77
CITY OF CUPERTINO `�"^' ` " "
BUILDING DIVISION PERMIT CON�TRAC�TORiINFORMATION.
BUILDING ADDRESS: PERMIT NOO 4 0 8 0 2 0 3
211 RTrPrPF.P C)AK ST
M'S NAME: PERMIT ISSUE DATE
ANDREW
NONE: SANITARY NO. CONTROL NO.
ARCHITEC lENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION lb Description
s C I M1cmby affirm
UZ00 Nat 1 am licensed under proWmo
v
u of Chapter 9(commencing
$ with Stttion70n0)ofDivision 3 of Ne Business and Profcssium Code.and my licenso is
<% in full force and effect.
Liz License Class Lica REMODEL--LIVING ROOM/BATH
nFn Date Contractor /
dry ARCHITECTS DECLARATION
,a IunticrstanJ my plans shall he used upublic records I�®
3r u qpa
''O Licensed Professional
g OWNER-BUILDER DECLARATION / ]'
iY 1 hereby affirm Nat I em exempt from the Cim rxaor's License Law far tM
00 following mason(Section 7031.5,Business and Profusions Code:Any city or county V 7005
vm which resolves a permit to ennamat,tiro,.improve,demolish,nr apair any shucum
prior m its issuance.also myuires the applicant for such Permit to rile a signed statement
Nat be is licensed pursuant toWeprovisions ofNoConuanur'sLicemeLaw(Chapter 9 Sq.Fl. Floor Area yycs��, Valuation
FVFG (commencing with Section 7")of Division 3 of the Business and Professions Cmle)tar L j-s + p
$
that he u exempt therefrom add time basis for the alleged exemption.Any violation of .{, y a R&!�'.`�
Section 7031.5 by ury applicant for.permit subjects Ne applicant to.civil penalty of 3 2 Ne10 0 meup3riq`'-T
not mart than five handled dollars(g500).
ype
❑1,as owner of Ne property,or my employees with wages im Neo sole compensation,
will do We work and We structoa is not intended proffered for sale(Sec.70x4,Business
and Professions Code:The Contractor's License Law does not apply to in owner of Required Inspections
property who builds or improve.thereon,and who dons ouch work himself or through his
own employees,provided Nat such improvements tie oat intended conferral forsale.If.
however,We building or improvement is sold within one year of completion.the owner.
builder will have We burden of proving Nat he did not build or improve fur purpose of
sato.).
1,as owner of We property,am exclusively convening w licensed contractors m
construct We project(See.701,1.Business and Professions C :)The Convacho
cense law Nrsnotapplymanownerafpmperry who Wil or improwtbamsm.and.
who conuactsfor such projects with a contr.ctor(0 liana ...110 Ne ComracmYs
License Law. z
l am exempt un TSec. .Bk PCfo Nisrt n
e Dam e( 9
WORKER'SCOM SATAON��DF.Cbt/RATION
1 hemby,a/fum ander pcnahY of perjury ones following doels nkma:
1 have and will maintain a Cenificateoconsenuo self-insure fm Worker's Compen-
sation,W provided for by Section 37M of We labor Code.for We Performance of We
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation li sunna,as requited by Section
311,f the labor Code.for We perfmmance of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number aa:
Career: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not WcomplemJ tribe Permit is foroachundrtd dollars(5100)
n less.)
1 certify that in We Performance of We work for which this Permit is issued.l shall not
employ any person in any...at.u to became subjttuo d¢Woders'Compenmtimi
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of We labor Code,you miss
.,z forthwith comply with such provisions or this Permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hemhy affirm that thele is a conavunion lending agency for We Performance of
G'
We work for which this pamnit is issued(Se:.3097,Civ.C.)
!1]Q Lender's Name
=z Lender's Addle..
U C) I certify that 1 have mad Nis application and sum Nat the above information is
f-' confect.1 agree to comply with all city and county ordinances and state laws rotating 0
0U building emiumleion,entl hereby admOrim repcienutivss Of Niscitymcnmrupnn Ne
}' ahovc-mcntiuncd property for inspection/Em"
G (We).gra to save,indemnify andss thc City of Cuertino against
lubilitiu.judgmcnts,costs and expenses nywayaccmeagainstseidCity
Uz memoreyucncc of c6ranting of Nis PerAPPLICANT DE ANDS ANO LY WITH ALL NON-POINT Issued by: Date
s0 ER ULA NS.
L u 2 Z' " Re-roofs
,$.at.. Ap,ImxdUCon mr au
H RIALS DISCLOS Type of Roof
__Wdl We applican Of future building occupant store or handle Intardous material
efncd by the Cupertino Mu icipaI Code.Chapter 9.12,and We Health and Safety
,eion2ss32(a)+ Na All roofs shall be inspected prior to any roofing material being installed.
will74 Nc applicant or future building occupant use cyuipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
omit W ardove air contaminants 11
defined by the Bay Ama Air Quality Managcmcm all new materials for inspection.
District?.
Yes Nu f
/l have mad the harar ous materials myui ems under Chapter 6.95 of Ne Califon
.to Health h Safety Code,Sections 25505,2553 42553,1.l undersunJ that lithe building
docs not cu dy hast a tenant.Nat it ism rtaponsibility to Imti�. l Nc
royal mane mnprinrtoi a ccofaccmfieaaoSignature of Applicant Date
..xdse All roof coverings to be Class"B"or better