04070112 CITY OF CUPERTINO a
RACTOR INFORMATTQN`le
eulLDlrvc DlvlsloN PERMIT �C 'N,Rr=
BUILDING ADDRESS: PEIIMIT N00 4 0 7 0112
4Q1 CASTINE All
OWNER'S NAME: PERMITISSUE DATS
CATHERINE
E: SANITARY 0. C AOL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG HLECT PLUMB MECH
0
v o o LICENSED CONTRACTOR'S DECLARATION
E9 hartby a R m that 1 marlin,
m licensed under provishme.f Chapter 9(ammuming Job Description
—� nifullfo deR afpDiviaion]af Neil nm and Profusions Cod,arW mYlutmls
=Z Lima � Le 32�fG3S REMOEL--DOWNSTAIRS BATH TUB/SHOWER
Dem Conl�w NO NEW PERMIT ISSUED/ORIG. #04050154
ARCHITECTS ATION CONTRACTOR: GK CONSTRUCTION & DEVELOPMENT
I un an..had
shW he used u public records
OyU
it G License Ifcu
OWNER-BUILDER DECLARATION
eI I hereby.(Stns met 11. acmpe from No Ossium o License taw for the
02 following mann. (anti t 7031.5.Business and ve de tens Code:Any city or county
$(L
which requires•permit ac enres led alter Improve,demolish.i m repair any torment
thatWor 0iucensdpursuntto ft ledappforsuch permit in cause, ned aw(Cltem.m
F (commming,edPurwanu0thoprovivisio n oftheBlrsetuhnlamLaw(C ode)at Sq.Ft.Floor Area Valuation
cf $ that he Is moment
Sa0an7nnd Was far
the
theBusinessesaand
ose.My professions Code)or
—
that he ts ese.npl duefrom and Uu buts(m tie alleged esemPtion.MY violeYa of so
Section 7031.5 by any,applicant for a permit subjens the applicant in a civil Penney of APN Number Occupancy Type
not mom dun Ow hundred io1Ws($500).
❑I.um mof Uepopeny.mmymploymwlmwegesuftirwte=pcmtim.
willdo Uk work,and the suumurelsrulinmMei«altered farsau(Sam.761/,Busituu Re aired GLIGIIS
And PrefeWom Cade:The Canuenoh License law dean eat apply to an owner of q
property who bulldsur(mproves thmeon,and whodeassuchwark himselfor Waugh his
own employee,provided that such improvements Am not Intended oroReres for We.if.
however.the building or Improvement Is sold within am you of compledon,me owner. )
bulkier will have de burden of proving that he did not build or Improve for purpose of
sale.).
O T.as owner of du property,am aclusively conoantins with licensed canuacwn to
construct the project(Sec.7014,Business and Profeaslons Cade:)The Connector's Lt.came law does not apply m an norma of property who builds or improve thereon.And
who contncis for such pmjeeu with a conuactar(s)licensed pursuant in the ComncmYs
License law. .
El I Am tmmp.under Sce, .B A P C for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby atlinn under Penalty of Perjury am of the fallowing deckua ion:
have end will maintain a Cenkficue of Consent to air-insure for Workmen Camper-
Winn,an provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Wmkeh Compensation Luuranm,As required by Section
3700 of the Labor Cad.,for the performance of the work for which this Permit is issued.
My WorkerAl,Cn�IPtpema ,n Inswgna carrier and Policy number am:
Court .5 ^� polity N I"�79�
CERTIFICATE OF EXEMPTION ORKFRS'
COMPENSATION INSURANCE
rrhissemlea hams nolbecamplemd if tin permit is form handed dollars($100)
ar 1c W.)
I certify that in the performance of the work for which this Permit 4 issued.I shall not
employ any person in Any manner0 AS m became abject to the Worker'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificak of Exemption,you should
become aobject to the Worker's Compensation prevision or the Labor Conic.you must
.JO forthwith comply with such provision or this permit shat]W accrued evaked.
tiCONSTRUCTION LENDING AGENCY
(r I hereby affirm that then is a ctunactinn lending agency for the performance of
fY.> the work for which this permit 4 issued(Sec.3097,Co.C.)
QLenin's Name
=z Landau Add=
U Q I ttnify that I have reW Ws application and rete that the abow ofmrem.a I.
f' correct,1 agree to empty with all city ane county ordknsa
ns and sue law entities to
QU building construction,and hereby authode mpreunulives of this city to enter upon the
alcove-mendomd property for inspection purposes.
LL (We)agree to saw,indemnify and kap nameless he City of Cupertino against
ti
liabilities,judgment.cats and expenses which may in Any coy accrue against mold City
U Z in consequence of the granting of this permit.
�--�
APPLIC6AFT,UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 t
SOUR LA S. /
�/� Re-roofs
Signe— u� onteactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant aloe of handle haesdous nu urial
As dcOncd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Chun,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y �No
Will the App]icantorfuture Wildingattupont use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to re eve
It haurdr.air canummanu As defined by the Bay Area Air Quality Management all new materials for inspection.
urictT
C]Yes D5?7u
I have mad me henmduus materials requirements under Chapter 6,95 or dk Califor.
n4 Health k Safety Code.Seemas V5505,25533 and 25534.1 undcreund thatlithe building
does not a rrem haw a knan4 that it Is my responsibility m ratify the occupant of me
requlrtmcnu mast Ipoor atlumme.f.carat oracuy y. Signature ofApplicant Date
r.atharisd en '2 All roof coverings to be Class"B"or better