04080271 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ONTRAC�T,OR�IINFOUMATION �E '
BUILDING ADDRESS: PEIIMff NO,U4 0 9 0 2 71
OWNER'S NAME: PERMIT ISSUE DATE
ROY K KOZEN E; SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION JbDescri tion
ZC oP I hamby affirm that I am licensed under provisions of Chapter 9(commencing
<b with Section 7"jaf DMaon S of NC Business aM Profesuam Code.and my license is
infall farm anaercat REVISION--IN HOUSE USE ONLY
D aM z Leon.Class Lic.a
�oDam Contractor.
tj ARCHTIECT'S DECLARATION NO NEW PERMIT ISSUED/ ORIG. #04050155
Ny I understand my plans shall be used as public records
DaU
0 G Licensed professional
OWNER-BUILDER DECLARATION
'u I 1 hereby affirm Nat 1 am caempt from the Comracmfs License Law for the
x 0 0 following reason.(Section 7101.5,Business and Profession,Cade:Any city or county
y m Is which requires a pcmiit In eoruuuct,alter,improve,daMOILzh,fir repair say sructum
prior in its issuance.also requireathc applicant for such permit to file a signed statement
that he is licensed Puuuam to on provisions of de Common's Licens,Law(Chapter 9 Sq.FL Floor Area Valuati($Ii15
c�0 (commencing with Section 7o00)of Division 3 of the Business and Profession,Cons)or
as that he Is exempt therefrom and the basis for the alleged exemption.Any violation of
a.
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(5500).
01,ssowncrofNepmpmymmycmployceswiNx+gc wa irmlecomNnution, 35701040 . 00
willdatheworkandtheswcmmisnotintendedoronert for3le(Sa.70x4.Business
and Profeaama code:The ConuacmYs Limens,Law does not apply to an Owner of Required Inspections
property who builds or improses thereon,and who does such work himself or through his
awn employers,provided that such improsemanu ara not intended nroRcred fm tile_If,
however.the building or improvemen is sold within one year ofnemplenion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of / \
I,as owner of the propcny.am exclusively contracting with licensed contractors to
consumer the project(Sec.7044,Business and Professions Cade:)The Conuacmr's Li- �(
ccn,e law dors not apply in an owner of property who builds or improves theman,and
who contracts for such projects with a convacmr(s)licensed purauam to the Contracmfs v
LkerLse law.
0 1 am exempt under Sec. .B&P C far this rcuon
Owae Data�'/�29�ry
ORKER'SC PENSATION DECLARATION s
I hereby affirm under pcnalry of perjury one of the fallowing doclars ions:
but and will maintain a Certificate of Consent to self-insure for Worker's Compen-
=lion,as provided for by Section 37W of she Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Iwrrance,as required by Section
3700 of the Labor Code,for the peRormanee of the work for which this permit is issued. -
My Wnrkch Compensation Insurance carrier and Policy number arc:
Carried Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r -
(ILa ace ian recd not¢completed if the Permit is fortune hundred dollars(SIM)
or los)
1 certify that in the performance of the work for which this permit a issued.I shall nut
employ any person in any manner an as to become subject in the Warkeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccdifcale of Exemption,you should
become subject to the worker's COmpemmion provisions of the Labor Code,you most
.,2 forthwith comply with such provisions or this permit shall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
'f^-N I hereby affirm that there is a commutation lending ageay far the performance of
(Yi Ne work for which ma permit is named(Sec.3097.Civ.C.)
tt7 Lenders Name
Undeis Address
az
U O 1 gree that 1 have mad this application and sum that the above information is
Fcorrect.l agree to comply with all city and county ordinances of and sum laws relining e
pU
buildingconstruction.pm.and herebyauNonprcpremnutixesof this city to enter upon the
aMvc(we)agre to cnyraw.for imnify an keeses.
F C (We)agrees,cost,indemnify and keep harmless the City of Cup Inst s idagainstty
N liabilities,judgments,costsand expenses thisPermit. may in any way acvuc against said City
U Z in APPLICANT
NDERf the TAN of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULA ONS.
'Z _ ,z o Re-roofs
` gmmr ofAppliL ACZARDOUS MATERIALS DISCLOSURE te Type of Roof
Will the applicant or future building Occupant store or handle harmdous malarial
as defined by the Cupertino Municipal Code.Chapter 9.12.and Ore Health and Safety
ilit
.Section 25532(x)?
❑Yes ]No All roofs shall be inspected prior to any roofing material bein installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
ict? \'
❑Yes IfINa
I have mad the baaarthme matanals mquircmcnu under Chapter&95 ortM Califor-
nia Health&SafayCOM.Sanaa 25505,25533 and25534.I understand this drive building
dors not couni haw a mans that it Is my responsibility or Witty de occupant of the
reyuyebeet rimraaeeuiroOepany. Signature of Applicant Datewan
of-
Ownc,
Ora hodzad t Date All roof coverings to be Class"B"or better