05060046 CITY OF CUPERTINO W'3 , �`�^
BUILDING DIVISION PERMIT 6C0N 1R `CT RANFQRMATIQN .
f ��t 9 a
BUILDING ADDRESS: COUTTOLENC NEFTE PERMTI 1005060046
OWNER'
— 909 ETTSTO CANON
.,NG: SANITARY O. CONTROL NO.
ARCHIIECS/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
°00 LICENSED CONTRACTOR'S DECLARATION
iC I thereby alarm that 1 am licensed under provisions of Chap¢r 9(commencing Job Description
testa with Scmion70kfBof Out
3 of Na ..
e Bh„ and Professions Code,and my licenseis
^ in full forte and effect
7�g LicenseClh4 Lic.itREVISION--MS . BEDROOM
�, Dam Cottonton—
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. 304110145
?W U 1 understand my plans shall he used as public records
C.t�, Licensed Professional
`OS OWNER-BUILDER DECLARATION r
<v 1 hereby infirm that I am exempt from the Contractor's Liecnse Law for the
O O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
c, which requires a permit to eonstrun,alter.improve,demolish,or meat,any suuctonc V
�Zy poor to its issuance.also mattiras Ne applicant for such permit to rile a signedauumcm
that he is licensed pursuant to be provisions of the Comracmr's lJa•.•Law(Chapter 9 Sq.Ft. Floor Area \� ValuatiOB115
Mtn (commencing with Section 7000)of Division 3 of the Business and Professions Code)or � 5'
y Nat he is exempt tixrt(rom and Ne bash for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects use applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five huwmd dollars(5500). p y YP
1,as owner of the property,or my employees with wages as their sole compensation, 37518016 . 00
will do the work,and to structure is not intended aral@red foralc(Sec.7064,Business
and Professions Code:The Contractor's License Law docs not apply in an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
Own cmployca,provided Nat such improvements art not inmnded or offered for sale.IL
however,Ne building or improvement is sold within one sear ofeampledon,the owner-
builder will have the harden of moving that he did not build or improve far purpose of
sale).
❑1,as owner of the normal,am matunimly contracting with licensed contractors to
construct the project(Sec.7046,Business and Professions Code:)The Contractual Li.
cense law docs not apply in an owner of Formerly who Wilds or improves theman.and
who contracts for such projects with a eontramel licensed pursuant to Ne Contrail
License Law.
tn Iota egCxetopt under Scc. .B&PC f�oorro)is hon
mer C! WORK CO 7/AAO DION/ V
' of
WORKS§COMNSATION DECLARATION// %%
1 hereby aRmm under penalty of perjury one of the following declarations:
t]1 hive and will maintain a Certificate of Consent to self-insure for Worker's Compel
station,u provided for by Section 3700 of be tabu Code,for the perfmmance of the -
work for which this permit is issued.
El 1 have and will maintain Wal Compensation Insurance,h required by Section
37M of the Labor Cod,for the performance of the work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thismetion need not M completed irthe permit is forone hundred dollars(SIS])
ar lca.l
I certify Nm in Nc performance of to work facwblch Nis permit is iaucd.I shall not
employ any parson in anymanna trso ,subiccito IM Workers Compensation
Laws of California Dom
..CC OO 11
Applicant i' , C n
NOTICE TO APPLICANT:If.after makonfutrCcoificina of Exemption.you should
become subject to the Workers Compensation provisions of be Lahur Code,you must
.J Q fool comply with such provisions or this permit shall he deemed revoked.
z` CONSTRUCTION LENDING AGENCY
'tar I hereby affirm that Nem is a constioll lending agency for the performance of
Cls > the.,it far which this permit is issued(Sit .NA7,civ.C.)
W A Lender's Name
}Z Lender's Address -
U C I cenify Nat I have rad this application and sure Nat the show information is
ly f" contact 1 agree to comply with all city and county ordinances and sum laws falling to
pU building construction.and hereby amhove rommacuuriva of this city to enter upon the
r� libum-mentioned property for inspection purposes.
I„r y (We)gree to save.indemnify and keep harmless the City of Cupcnino against
h Iiabiliues,judgmenu,cos and expenses which may in anY tray accrue against acid City
UZ in conseqummo of thcg ting of is meront.
'—' APPLICANT UNDE TAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAfish S
X) Re-roofs
Signalmen n o factor Data
HAZARDOUS MATERI LS DI CLOSURE Type of Roof
Wili pplicam orfmurt buildig occupant swrc of handle havardaus meurial
a defined by c Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Se,
)IV,
INu All roofs shall be inspected prior to any roofing material being installed.
A If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant infuture building by the B y A ea Air au or Mara which g
nit harardnus aim mnuminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
Oisirin?
❑Yes �u
1 have mad the haardouammerials requirements under Chapmm6.95 of Ne Califor.
[HCslO&SafmyCw no.25N)5.25533 end 35534.1 understood thmifNc holding
s not currently ho a unam.tha t is my responsibility to notify the occupant of the
Oramems� ustbe et rlaissuarecofecertr0aml f Oc spa rSignature of Applicant Date
4 ° All roof coverings to be Class"B"or better
a a
Data
CITY OF CUPERTINO W'3 , �`�^
BUILDING DIVISION PERMIT 6C0N 1R `CT RANFQRMATIQN .
f ��t 9 a
BUILDING ADDRESS: COUTTOLENC NEFTE PERMTI 1005060046
OWNER'S NAME: PERMrI L55UE DATE
TAg(�N gPFNr7,R — 909 ETTSTO CANON
.,NG: SANITARY O. CONTROL NO.
ARCHIIECS/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
°00 LICENSED CONTRACTOR'S DECLARATION
iC I thereby alarm that 1 am licensed under provisions of Chap¢r 9(commencing Job Description
testa with Scmion70kfBof Out
3 of Na ..
e Bh„ and Professions Code,and my licenseis
^ in full forte and effect
7�g LicenseClh4 Lic.itREVISION--MS . BEDROOM
�, Dam Cottonton—
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. 304110145
?W U 1 understand my plans shall he used as public records
C.t�, Licensed Professional
`OS OWNER-BUILDER DECLARATION r
<v 1 hereby infirm that I am exempt from the Contractor's Liecnse Law for the
O O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
c, which requires a permit to eonstrun,alter.improve,demolish,or meat,any suuctonc V
�Zy poor to its issuance.also mattiras Ne applicant for such permit to rile a signedauumcm
that he is licensed pursuant to be provisions of the Comracmr's lJa•.•Law(Chapter 9 Sq.Ft. Floor Area \� ValuatiOB115
Mtn (commencing with Section 7000)of Division 3 of the Business and Professions Code)or � 5'
y Nat he is exempt tixrt(rom and Ne bash for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects use applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five huwmd dollars(5500). p y YP
1,as owner of the property,or my employees with wages as their sole compensation, 37518016 . 00
will do the work,and to structure is not intended aral@red foralc(Sec.7064,Business
and Professions Code:The Contractor's License Law docs not apply in an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
Own cmployca,provided Nat such improvements art not inmnded or offered for sale.IL
however,Ne building or improvement is sold within one sear ofeampledon,the owner-
builder will have the harden of moving that he did not build or improve far purpose of
sale).
❑1,as owner of the normal,am matunimly contracting with licensed contractors to
construct the project(Sec.7046,Business and Professions Code:)The Contractual Li.
cense law docs not apply in an owner of Formerly who Wilds or improves theman.and
who contracts for such projects with a eontramel licensed pursuant to Ne Contrail
License Law.
tn Iota egCxetopt under Scc. .B&PC f�oorro)is hon
mer C! WORK CO 7/AAO DION/ V
' of
WORKS§COMNSATION DECLARATION// %%
1 hereby aRmm under penalty of perjury one of the following declarations:
t]1 hive and will maintain a Certificate of Consent to self-insure for Worker's Compel
station,u provided for by Section 3700 of be tabu Code,for the perfmmance of the -
work for which this permit is issued.
El 1 have and will maintain Wal Compensation Insurance,h required by Section
37M of the Labor Cod,for the performance of the work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thismetion need not M completed irthe permit is forone hundred dollars(SIS])
ar lca.l
I certify Nm in Nc performance of to work facwblch Nis permit is iaucd.I shall not
employ any parson in anymanna trso ,subiccito IM Workers Compensation
Laws of California Dom
..CC OO 11
Applicant i' , C n
NOTICE TO APPLICANT:If.after makonfutrCcoificina of Exemption.you should
become subject to the Workers Compensation provisions of be Lahur Code,you must
.J Q fool comply with such provisions or this permit shall he deemed revoked.
z` CONSTRUCTION LENDING AGENCY
'tar I hereby affirm that Nem is a constioll lending agency for the performance of
Cls > the.,it far which this permit is issued(Sit .NA7,civ.C.)
W A Lender's Name
}Z Lender's Address -
U C I cenify Nat I have rad this application and sure Nat the show information is
ly f" contact 1 agree to comply with all city and county ordinances and sum laws falling to
pU building construction.and hereby amhove rommacuuriva of this city to enter upon the
r� libum-mentioned property for inspection purposes.
I„r y (We)gree to save.indemnify and keep harmless the City of Cupcnino against
h Iiabiliues,judgmenu,cos and expenses which may in anY tray accrue against acid City
UZ in conseqummo of thcg ting of is meront.
'—' APPLICANT UNDE TAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAfish S
X) Re-roofs
Signalmen n o factor Data
HAZARDOUS MATERI LS DI CLOSURE Type of Roof
Wili pplicam orfmurt buildig occupant swrc of handle havardaus meurial
a defined by c Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Se,
)IV,
INu All roofs shall be inspected prior to any roofing material being installed.
A If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant infuture building by the B y A ea Air au or Mara which g
nit harardnus aim mnuminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
Oisirin?
❑Yes �u
1 have mad the haardouammerials requirements under Chapmm6.95 of Ne Califor.
[HCslO&SafmyCw no.25N)5.25533 end 35534.1 understood thmifNc holding
s not currently ho a unam.tha t is my responsibility to notify the occupant of the
Oramems� ustbe et rlaissuarecofecertr0aml f Oc spa rSignature of Applicant Date
4 ° All roof coverings to be Class"B"or better
a a
Data