04030132 CITY OF CUPERTINO e r sisY di a<--�a°i���riyIf ltd
BUILDING DIVISION PERMIT t CONTRACTOR jNFORMATION
BUILDING ADDRESS: PERMIT NO04030132 4030132
ER'S NAME: PERMIT ISSUE DATE
1
ONE:MARTIN KELLER
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
w 1 Mreby affirm that I am licensed under provisions of Chapter 9(commencing Job Description y��,
U with Section7ro)(1)hf Division Sof the Basinvaand Profcnsions Code,and my liccnac is 2���❑ ��J
in roll Tome am erten, INTERIOR OPENINGS Il LL P
�jg? U.mc Class Lic.g
n�n Datc Contractor
�H£ ARCHITECT'S DECLARATION SEp 10 2004
'�K< I understand my plans shall be used u public records
JyU
u0 Licensed Professional
3 OWNER BUILDER DECLARATION t�1n'1n1 11 a1%
+E I hereby maso .('Sero that I oro exempt from the Contractor's License Law for the t�lY/�Ne®1•a
i no following mason.a(S.I.t ]ID I.S.B..1w. and Professions Code:Any tiny or county
E$ which its isec n permit re cores the aMr,improve,h Permit
t fie a sig any sevctuh,
ctinnn
Out er its iensMa alto pursuant
toif6lM applicantsof the ancContractors
to Ale a.Law(O@menn
5x0x
Out he is licensedpursuamw0mpmvisioroofthe CancocwriLicenwilaw(Chepwr9 Sq.Ft. Floor Area Valuation
of (commencing with Section 70r0)ofDivision J of the Business and Pmressions Code)or
that M is exempt Nererrom and Or basis for the alleged exemption.Any violation of
Section 7031.5 by ury applicant for a Permit wihjecu the applicant to a civil penalty of 3 G&NR`It®ter0 0 Occupancy Type
not mole Nan five hundred dollar
❑1,u owner ofthe pmpcny,m my employes with wages u their axle compcnutlon,
will do the work and Ibe swcmr is not intended oro@red forado(Sec.7044,Buvnus
and Pmfcssigv Code:The con oe ors License Law does cont apply in en owner or Required Inspections
property who Wilds orimprev Nercon,and who doessuch warkhimulfornhrough his
own employers,provided that such impmsemcns are not intended oroRerW forsale.if,
however,Or Wilding or improvement is wild within one year ofcomplevon.the owner.
builder will have IM Whom of proving But k did not Wild or improve for purpose of
sale.).
g{.1,v Owner or the progeny,am exclusively concocting with licensed contractor w
£instruct the project(Sec.7044,Business and Profusions Cade:)The Contractors Li-
ccnse law does not apply to an owner of property who Wilda or improv Neeson,and
who concocts for such projecs with a conwcou(s)liamed pursuant to the Contracting
License law.
Ej I. aempt undeSec. B&P C for Ni anon
e
WORKER'S COMPENSATION DECLAR
1 herby aRnn under penalty of perjury one of the following dechistions:
I have end will butouin a Certifies.of Covent w sol-hom.fm Worker's Compso-
urian,ss provided for by Section 3700 of Ne IaWr Coda.fm the performance of the
wmk for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u required by Section
J]00 of the labor Code,for tM performance of IM work for which this pemcit is issued.
My Wmkens Compewdon Insurance carrier and Policy number ane:
Carrier, Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITisscctionnecd no NcomplewdirtMpcmnit Hmronc WndmAdnBars($100)
Or toss.)
1 cenify Out in the perf gran nc.of the work for which this permit is issued.I shell not
employ any Neson in any manner so m in become wi ycet in tM Wortrrs Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Cereficae,of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Coda you most
.J O roMwith comply with such pmviswns Or Nis pe.itthall bd ra
e deemenked.
zDi CONSTRUCTION LENDING AGENCY
[-. I Mmby affirm Nan thane is a construction lending agency for the pcorurmamoc or
C4 the work fm which this permit is issued(Sec.309].Civ.C.)
aQ lenders Name
D z Lender's Addncss
U O 1 cenify that 1 have read this application and suit:that the AWve information is
t" correct.I agree to comply with all city and county onliwwes and sure laws elating to
0 building construction.and hereby autions,sepmsentuiv or this tiny to enter upon the
k[1 alwve-mentiuncd pm ony for inspection purposes
4. (We)agree no save,indemnify and keep mnnlecs IM City Or Cupertino against
Fh Liabilities.judgments.toss and expcves which may in any way see=against said City
U Z APPLIOof the gom In&Of tcolt
CANTUNDERSTANDSAND OMPLY WITH ALL NON-POINT Issued by: Date
SOURC iJL'1pT10NS.
Ill( _ 3 Re-roofs
cgnaz re ' HAZARDOUS
DOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future building occupant snow or handle huardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and IM Health and Safety
6Section 25532(a)7 Pl. All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applicant nr future building occupant use equipment gr devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havadnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Distria7
❑Yesu
I have read the hacarthms materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Cock.Steams 255(15,25533 25534.I undcruM due if the Wilding
does rot tmorid have a to ant.Ua1 it is in I tiny to hoary the occupant of the
mqui t.wh hmust Iroom WOda ceNficateorOccvpanTyv. Signature of Applicant • Date
owner gr an nrivcd argot DS,te All roof coverings to be Class "B" or better
CITY OF CUPERTINO y�r��}" "r ♦` t"'�"fir"
BUILDING DIVISION PERMI �`� h"CTO-RA E&AI
BUILDING ADDRESS: PERMIT NO04030132 4030132
20177 CLAY ST
OWNER'S NAME: PERMrf ISSUE DATE
MARTIN KELLER PHONE: SANRARY NO. CONTROL NO.
ARCHTIECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
j0 LICENSED CONTRACIOR'SDECLARATION Job Description
a 1 Tomb,affirm Nat 1 am licensed under provisionsof Chapor 9(mmmcncing
i:� with Section 7")Or Division 3 of the Business and Professions Code.and my license is 2
in full forom Lecrucclass m INTERIOR OPENINGS
30 Dam Clan Lisa
:� Deo.Contra=
ARCHrrECrS DECLARATION .t
LU I undusund my puns shall Ic urA u panic rtards SCP 10 2004
't Licensed Professional
5 OWNER-BUILDER DECLARATION
1 hereby affirn that I am exempt from the Contractor's Limns,Law for the BUIL`DING
20 following Munn.(Seeuon 703 1.5,Business and Profemank Code:Any city or county BUILDING
v(v
which inquires a permit to construct,alar.morrow.demolish,of repair any structurenon
t� primch its ise....un,requires theapplicent for such Permit to rileasigmd rooms.1
ip that heis licensed pursuant tomeprovisionsofthe Contractor's LicenseLaw(Chmwo9 Sq.Ft. Floor Area Valuation
—n (eommennng with Samoa 7M(1)of Dw[ma 3 of the Business and Profesimns CodC)or
_ that m u exempt therefrom and the bold fm the alleged exempt oro Any violation of rwnn�s
Section 1031]by ar y applic nd for a permit subjects the&PPIMs t to a Chill penally of 3 I�.IjIM&Ier0 0 Occupancy Type
On more than rive hundred dollars(5500).
❑1.u owner of tit property,a mY cmploycrs wW wegu u neuolc ampensauon,
will Cloth,woh.and thestmmum isnot intended m offered formic(Sec.104/,Business Required Inspections
and Professions Cade:The Common's Linn'Lew does not apply to an owner of q P
property w ho builds or improves thereon,and who dors such work himself cathmugh his
oven employers,provided thatsoh improm gents art not in ars ded croffered for sale IL
howem.Ne building or improvement is old within ane year of completion.the owmr-
builder will have the burden of proving that he did not build or improve far purpose of
sale.).
L u awnv a the property.am excluuvcly counseling with licensed Controm a m
nstmn the pro ser(Sec.TON.Business end Rofe"Che Code:)The Conuacmr's U.
canoe Taw dors not apply an an owner of property who hall"or,.mprom thereon,us
who contracts far such projects with a commoror(s)licensed pursuant to the Contromfs
License law.
❑I am exempt undc Sce .B k P C far NI reason
are
n
J WORK ER'SCOMPENSATIONDECLAR
I mraby affntm under penalty of perjury arc of the fallowing Clecluations:
me and will maintain a Ce,iriesre of Consent to ol6insure fa Wmaces Camper'
on.as provided far by Section 37t10 of the labor Code,rim the performance of the
wort far which this permit is iuuel
1 baa and will maintain Worker's Compensation Insurance,u required by Section
3)00 of the labor Code.for the pcRormame of the work for which this permit is Issued.
My Workers Compcnsauon Insursom carrier and Poliry number are: _
Comet-. policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mr's section need not Ise completed if the permit is farm=hundred dollars(SIM)
or less)
I ar il,that in the performance of Ilse work for which this Permit is issued,l obeli urn
employ anyperson in any manner eco o o become subjmuo the Warkeri Compensation
Laws of California Dam
APit sent
NOTICE TO APPLICANT:If,after making this Ccnifscvo of Exemption,you should
become subject no Ute Worker's Compensation previsions of the Labra Code,you must
0 foMwith Comply win such pfnvisiom or Our permit shall be accrued rented.
I= CONSTRUCTION LENDING AGENCY
I hereby M.But tM as Construed..lending alum,far the performance of
'> the wait for which nu permit Is issued(Sec.3091,Civ.C.)
I Q lender's Name
)z Inndcrs Address
)C) I,unify that 1 have read this application are sum Lou due shove infarmauon is
F eoronf l agree o comply was all city and county ordinances and sure laws relating as
�U building construction,and hereby audeona,mpreonmim or this city to enter upon use
.I!] aWa-mentiaod property for inspection Puspmer. /
gy (We)agree to sax,indemnify and keep batmlest the City of Cupertino against
p) liabilities,judgments,costs and expenses which may in any way acemc against mid City
)z in eonsequena of rte granting of this perm,.
'—' APPLICANT UNDERSTAND AND OMPLY WITH ALL NDN-POINT Issued by: Date
SOURC TIONS
3 L Re-roofs
HAZARD USMATERIALSDISCLOSURE D� Type of Roof
Will rte applicant Or future building occupouom or handle huardou material
as darned by tits Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(411 All roofs shall be inspected prior to any roofing material being installed.
0Yc yyo
Will rte applicant or rltlluutore Wilding occupant iso equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
haesrdous air contaminants u dcfrmd by the Bay Am Air Quality Management all new materials for inspection.
ff?
❑yes
�
1 have read the basasdous maorials Mquitemenu under Chapwr6.95 of rte Califor-
meHcalth&SafctyCodc,Se<vons 25505.25533 25534.1 undersand tudiftM Wilding
does int cuncntl have• l this it u m ih0ity o nod(,the occupant of etc
recut wit Amass tpdafw' or.ac,mrcamartxapanq. SignatureofApplicant Date
> All roof coverings to be Class "B"or better
Owner or m mind.gem Dau