05030260 CITY OF CUPEA'1'INO *` tw-`*M ' *' "' "•° `' - ' `
BUILDING DIVISION PERMIT r�.CONTRACTORINFORMATION `'
BUILDING ADDRESS: PERMIT NO.
05030260
OWNER' NAME: FERMITLSSUEDATE
NE:
SANITARY ROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
w F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
<E with SCmlen 7000)of Division 3 of Ne Bushes and professions Code.and my licensee
in full force and eneeL
License Class [2 Lic.g d ✓Sr+� 7 - ADD 132 ' (DIN. RM) & REMODEL KIT. &
�� Damy—G _roCH CmunchoTS DEL o o tors BATHRM/REPLACE WINDOWS (9) & 1 SLID. DOOR
ARCHITECTS DECLARATION
soudrsandmypmnahaneused upublic menm CONTRACTOR- ADAM SANDERS
3 u l-
0 Licensed Pon(euional
rev, OWNER-BUILDER DECLARATION
Y 1 hereby M.Nat I am exempt fsum the Comrecmrs License Law for the
O O following reason.(Section 7031.5,Business and Pru@ssiom Calc:Any city or county
K m E! which.quirts a permit to construct,arm,,improve,demolish.or¢pair an,uruclure
at prior to its issuance.also requites the applicant for such permit to file a signed statement
that he is licensed pursuant to the previsions of the Commerce's Lteenie law(Chapter 9 Sq. Ft. Floor Area - Valuation
¢F$ (commencing with Section 7W)of Division 3 of im Business and Profession Code)or
that he is esempl therefrom and sbe basis fa do alleged exemption.Any violatfan of
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of APN Number Occupancy Type
not mom Nan Eve hundred dollars($500).
❑I.uowmrofOmpmiscey,ormycmploymwithwagaudeirwlccompcnudon,
will do the work.and the structure is notinanded or offered(oraalc(Sm.7BM,Business 35701042 . 00
and Professions Code:The Conmaon License law docs not apply to in owner of Required Inspections
property,who bis ills or improves shenron,and who does such work himsel f a through his
Own cmployas,provided that such improvements arc not intended oroRcad for We.If,
however,the building or improvement is sold within one year of completion,the Owner-
�1
builder will ban e burden Of proving that he did not build or imrove pfor purpose of I'
talo.). Nn
❑1,as owner of the property am exclusively contracting with licensed eomncters m I
comma Be project(Sec.7049.Business and Profession Code:)The Contractor's Li-
cence, m Li- pp
ceLaw docs not apply an owner of property who builds or improves thereon.and � /:Ih J
who contracts for such projects with a comracmr(s)homed pursuant int he Conmacmra v t11,
License Law.
El I am exempt under See .B&P C for this mason rtT
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby of man under penalty of perjury one of the following dectautions:
new and will maintain aCo-I ficam of Consent to self-insure for Worker'aCompen-
on,u provided for by Section 3700 of the labor Code.far the percmance of the
work for which this pewit is is tad.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
3700 of the labor Code,fa dm pedi marm Of the work for which this pewit is issued.
My Werke/(s Campo AU71nwo na exact and Policy number aa:
Cartier.b-As1( !�e:Nn F Policy No.: _
CERTIFICATE OF EKFMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he compiemd if the Nora t is for one hundred dollars($1110)
to kis.)
1 certify that in the perfnmanec or c rk for which this permit is issued.I shall not
employ anyperson in any as keen yr(GeelmNe Warkeri Compensation
taws of Cilifomia:
Applicant
NOTICE TO APPLICANT:If,after making this Certifficam-oF Exemption,you should
become subject in the Worker's Compensation previsions of the labor Code,you must
.,z forthwith comply with such provision or this pewit shall he damod evoked.
z O CONSTRUCTION LENDING AGENCY
[--�� I hereby affirm that there is a consructinn lending agency,for the pertomanee of
Z' 7 the work for which this permit is issued(Sce.3097.Ci,C.)
1.4 A Lenders Name
=z lender's Address
U C) 1 certify that 1 have mad this application and sure that the above information is
U,Hm
coet.I agree to comply with all city and county ordinances and sum laws Blaring to
CU building construction,and hereby authoom apasenutiuv or this city to enter upon the
W above-mentioned property for inspection purposes.
6. (We)agree to save,indemnify and keep harmless the City of Cupertino against
py Iiabilirma.judgmenu,costs and expenws which may in any way accrue against said City
U z in consequcncc of the granting of this permit.
APPLICANT UN_DE ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE RE S.
11�> y 6 —�J Re-roofs
Signau of ApplicwUCanvwmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theapplicantor furore building occupy stere mhaMle haramous metadal
as defined by Be Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Cook.Schon zsvz(.)?
❑YeCa No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
hvamous air contaminann as defined by the Bay Area Air Quality Management all new materials for inspection.
rice,
❑Yea E]No
1 have mad the ha a d ous mawrlals requirements under Chapter 6.95 of the Califor-
nia Health&SafctyCode.Secuom 35505.25533 and 25534.1 understand that if do,Wilding
des not currentlyha aa Nat it u asp9mibility m mttiry Ne acupant of Ne
ByuimmenB soh' u mel pri aanaora cemEi of Occupatry. A onature of Applicant Date
All roof coverings to be Class"B" or better
Owner or lubmi agent Data
L