04060044 J.UIIDING
Y OF CUPERTINO ax ' =*'am. � �� '%" "" -``
UILDING DIVISION PERMIT CONTI2 ET�ORINF'�ORMATION
ADDRESS: PERMIT"04060044
04060044
'S NAME: PERMIT ISSUE DATE
FRANK
SANITARY NO. -- - - CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_op LICENSED CONTRACTOR'S DECLARATION Job Description
m❑ 1 Wmby affirm this 1 am lianxd ppppnJ,���9r provisions of Chapter 9(commencing
iW wish$ lion]0W)afDiv'sion3of the eushlNsand Professions Code, dmyliccve is
i I"(tme`and eel .��``as 7s5 / ADD 1587 S . FT. (FM KIT SUTDIO MS BED,
^�i .LDa Class Conte r SQ
. FT.
ARCH ECTS D AT ON BATHROOM, & GARAGE 430 SQ. FT.
¢ode ticraunJmyplansshellWuxJu nnfiartaw CONTRACTOR: W A FARNHAM CONSTRUCTION
JyU
,GI
h Licensed Pnrfcsionel
S OWNER-BUILDER DECLARATION
1 hcmhy affirm on 11. exempt faro she Cssions o License law for she
po followingroaenn. meront ](131.5,Business and improve.
de inrm Code:Any city or county
tell which requiresm permit to pursuer alter,improve.demolish,fie a sigany meamal _that
in its tensed pursuant rets require tM applicant for such.corms mice s signed su¢mcm
(commescansed tion 7Mc provisions of she Cnnluctor's eas rd Pro Laws Code) 9 Sq.Ft. Floor 5� Valuation
(commencing exempt acreianst tied of Diaiiion3 of sheegei exemption.
Any
or
Net he u exempt Ncafrom and the baso for am alleged exemption.Any violation of
SeNon 7031.5 by any eppliesns for is —it subjects she applicant his a civil Penally Of APN Number Occupancy Type
net more Nan five hundred dollar(SSOOh
❑1,as owner oNie property,or my employees with wages as their sole compensation.
will do the work.end Nuwaurt is not imm�dW or attcrW Inosite(Stt.]DU,Business342 14 084 . N
and Professions code:The Conuanoes Live Law does not apply to an Owner of RegUlr pectlODs
property who builds or improves thereon,and who doessuch work himself or through his
Own cmplowes,provided that such improwmcou sum notimended or offered for sal,If. �� 1
however,the building or improvement is sold within one year ofcompletion.she Owner- ems!■
builder will haw the Widen of proving that he did not Wild or improve fur purpose Of ®�11 Atp�]mor,
sale.).
❑I,as owner of the property,am exclusively contracting with licensed convectors to
construes the pre)ttt(Sec.7004,Business and Pmfasions Cade:)The Convenor's Li
scrum law does not apply no an owner of property who Wilds or improves thereon,and
who contracts for such projects with a comacmr(s)licensed pursuant w the Convectors
License law.
I am exempt under Sec. ,B&P C for this reason
ICor Date
WORKER'S COMPENSATION DECLARATION
I hereby affrse under patty of perjury one of she following declammers:
haw and will mainuin aCenificalc of Consent to self-insure for Worker'sCompen-
n,as provided for by Section 3700 of the labor Code,far the performance of tine far which this permit is issued.
have and will mainuin Worker's Compensation Insunna,u required by Sectio of the tabor Code,for the performance of the work for which this permit is issued.
Worker's Co ppensation Insurance carrier and Policy number axA4%AwIA. o Polity Ny/mss a/v'7^Z
CERTIFICATE OF EXEMPf10NFRON,WORKERS'
Y COMPENSATION INSURANCE
•(Thistionnee not he completed if the permit is future hundred dollars(SIM)
or Icse.)
I certify that in she perfmmance of in.work for which this permit is issued.I shall nut
employ any permn in any manner so az m become subject in the Warkeri Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
blame subject to she Worker's Compmtradmn provisions of the Labor Cock.you must
.J O forthwith comply with such prnvisinno or Nix permit shall W deemed revoked.
z` CONSTRUCTION LENDING AGENCY
Fw I hcmhy affirm that there is a construction lending agency for she performance of _�---
C the work fur which this permit is issued(Sec.3097,Civ.C.)
lgd Lender's /
lender's Add Address C/
U 1 ccnify shot I have mad this..plication..it sum Nat the above information is
Ba f" correct.I agree to comply with all city and county ordinances and sum laws relating in
0U building comvucvon,and hereby authorim representatives of this city m enter upon Ne
Y' above-mentioned property for inspection purposes.
,r (We)agree to now.indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments.ensu and expense,whichmry in any way...agate"—it City
U in consequence critic granting it hispermit.
APPLICANT UNDERS A NO WILL COMPLY WITH ALL NON-DINT Issued by: Date
SO '
ULATII S -A 7-
� Re-roofs
nuurc of Appli_ _ ! /HAZARDOUS MATERIALS DISCLOSURE tor Date Type of Roof
Will she applicant or future Wilding Occupant store or handle haws material
irSlriml?
efmcd by the Cupertino Municipal Core,Chapter 9.12,and dee Health and Safety
c,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
t]Yes [�Nu
Will the applicant or future building ocapant use equipment or Jcvmax which If a roof is installed without first obtaining an inspection,I agree to remove
I hanmous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
�u❑Ycs
1 have mail she hazardous materials rtquirtmenu under Chapter 6.95 of the Califor-
niaHealth&SafmyGodc.Sec..25505.25533 and 25534.IuneersurW shazifshc Wilding
door nm currently haw a morim,that it u my responsibility 0 notify IN occupant Of the
mqa m W t rNisaanaofaccruficamcircr),,r Signature of Applicant Date
nor or auffimued aagscent 77 /FDate All roof coverings to be Class "B"or better