04040197CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONT_ RAC-°TORINFORMATION�,
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BmI.DING ADDRESS:
0411 CARMRN RP
CUPERTINO CONSTRUCTION INC
111ITNo04040197
R'S NAME:
PERMIT ISSUE DATE
E:
SANITARY 007 N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECr PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
rtby u 1 an licensed under provisions of Chapter 9 (commencing
I oaffirm N
p
with Secuon 7001) of Division 3 of the Business and professions Code. and my license is
in full forte and effect q
License Class 6 Lk.a 7k�B 9dP
'
2 -STORY SFD (3500 SQ.FT. LIVING SPACE)
Date Comment,
GARAGE 484 SQ.FT.
ARCHITECTS DECLARATION
I undereund my plans sf ail he , u public acnrG
J
FIN
Licensed Rm.adona)
OW NER-BUILDER DECLARATION
(1
1 ore.Burinfrom the ConuasCo License Law, for the
1 hreaso .(firm attempt
following reason. (Section ]N 1.5. Business and Professions Com: Any city Of county
on
O■■Y/��
ct, alter. improve, or pair any ssmsum
which rtquirn a Pmmit abet,
fs—
r quires h Perlia a
se Lawdgatemcnt
he its cessed urge. also t to to ftapplicantfor eacConummr's torile
that heencing wit pursuant w du provision of Nc Conuxwr's Law (Chapter 9
that
Sq. Ft. Floor Area
_
/ 2005 Va�u�t 0 0 0
Poor
(commencing with Section] DDB) tr Division and ion Cade) or
Business endon.
dr al An
Net he is exempt therefrom and Ne beau for Nc alleged exemption. Any violation of
APN Number
U11ne""''.g��
` F.g if 04cupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
dollars
not.(ort Nan five hundred (g500).
32650055. 00
- •t
aN �l�.a
I, as owner of do ro
❑ P Pmy,amy employees with wages Heir sole compensation,
(< ]: a•�
-' e
Required Inspections
will do Ne work and the structure is not intended or altered far sale (See.JB1G, Business
and Profession Cade: The Co^uacwrs License law does not apply w an owner of
,
property who builds or improves thereon, and who does such work himulf or Unit his
own employees, provided that such improvements art not intended at offered for sale. If.
however. Ne building or improvement is said within one year of completion. Ne owner -
builder will ban the burden of proving that he did Out Wild or improve far purpose of
ask L
❑ I, as owner of the pmpcny, am nelasinly conuasing with licensed amncors to
convect the project (Sec. RNC, Business and Professions Code:) The Conlncter's U.
acne law does not apply to an owner of prop.ny who Wilds or improves Merton, and
who contracts for such projects with aeortracut licensed pursuant in the Centractod
License law.
❑ I am exempt under Sec. . B k P C lar bio won
.or/ Date �j!K
WORKER'S CODINSATION DECLARATION
I dimity affirm under Penalty of perjury, one of the following decimations:
law and will maintain a Certificate te of Consento self-insum for Worker'sCommit-
tion, as provided for by Section 3700 of the labor Code, for the performance of to
work for which Nis permit is issued.
❑ 1 ban and will maintain Worker's Compensation Insurance, ss required by Section
37W of the labor Code, for the performance of the work for which this permit is issued.
My Worked>Compernauon Insunna artier and Policy number arc:
Cartier, C 4..7C.. _.ash` Y�� Policy No.:
CERTI ATEFlC OFEXEMPT1ONFROM WORKERS'
COMPENSATION INSURANCE
milt section need not W completed if the permit is for one hundred dollars (SLOO)
less.)
I ce ufy Nat in the performance of Ne work far which this permit is issued. I shall not
employ any person in any manner an as of become subjat w be Worams' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making his Certificate of Exemption. you should
become subject to the Worker's Compensation provision of the labor Codd, you mug
foMwlt comply with such provisions or NU Permit me] W account mvaked.
CONSTRUCTION LENDING AGENCY
I herby thi that is convection lending agency Inn the perfurmance d
eNem
which s
Nc work for which this permit is issued (Sec. 3097, Civ. C.)
Larder's Nam.
Larder's Addw
j I certify Nat I have read Nis rt,h pion and sus inn the move infrmam.. is
' correct. l agree to comply with all city and county ordinances and gate laws misting of
building convection. and hereby muninae mprne^utives of this city to enter upon Ne
above-(We)anedgm to gavy for inspection mcphar
agree t indemnify and keep harmless the City of against
(s
,saw,
judgments, againga
i liabilities,judgments, carman& eapenuswhich mryin any way aamc againtaaid City60
APPLICANT of the of permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 0'
SOURCEREOUL ONS.
Re -roofs
Type of Roof
'�- -
Signature of AppliandConusor Data I'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant sone Or handle haramoua manual
defined by the Cupenin t Municipal Code. Chapwr 9.12. and the Health and Safety
de. Semen 25532b.)?0
<
All roofs shall be inspected prior to any roofing material being installed.
Yet
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fretum building .,a, a. cquipmem Or devices which
. havardoum air contaminants a defined by tW Bay Area Air Quality Managcmat
all new materials for inspection.
vicl]
❑Yds 1018.
1 have read he hicarduus materials requirements under Chapwr 6.95 of the Califar.
me Hcalt& SafctyCode, Section 25505.25533 am1255X. l undendidil bas if N. Wilding
does our c.bit, hate a tenant, dot it is my responihituy Of noufy she occupant of he
rtgmrdmcnawhich mum tomet Nor Or instance oraccrircatearoe.upanry.
Signature of Applicant Date
J
All roof coverings to be Class "B" or better
owns ar aamorivnd as.nt Due