06090048 CITY OF CUPERTINO 3�r �ea,•�:+g+�a�(
BUILDING DIVISION
PER < V�itrg.l[!lQ�T•`_O 'A' Al I
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BUILDING ADDRESS: PERMIT NO.0 6 0 9004 8
22104 CLEARWnnn CT
OWNER'S NAME: PERMIT ISSIfE DATE
SHARON VIOLA
�; SANITARY N0. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION Job Descrition
1 many afrrm Nal 1 am licensed under provisions or Chaplet 9(commencing P
With Section 7010)of Division 3 ofthis Bus nev f wCade d j0."
inrallromeanderxL 2 BATHROOM REMODELS, NON STRUCTURAL
h q z Licetvc Cl • sac.P
ltucl Dam Can DEC
7 RCHfIECi'S DEC 1
1 udenunJ my plans Nall ae used u nuhlic recorm
hyU
Lia"cI P.,y"nal
'y� nan OWNER-BUILDER DECLARATION
a Z i gesso .Ent Nei 1 1. unmet farm the C Worms o License c Law for me
.o O fallowing meson.(Sedan 7031.5.Business and improve.
d slum Cade:Any city or county
f$ which require issuance.alsore cnresft alkn Impuaw,demnlW,or repair ed strmntum
-Z<
prior to I%tsenedpaluant10 ms tamvisk applicant rot mehPermit tocenseLnetsumment
•�O Nuwis licensed pursuant to me pmvialC"of the Contracmri License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Schon 7000)of Division 3ofineBusiussAMPwfessinnsCoEc)or $18000
Net he is"emit mAmfmm and Ian baso for the Alleged exemption.Any vloladon of
Section 7031.5 by any applicant for a permit Subjects the applicant m a civil penalty of APN Number Occupancy Type
not more than fin hundred dollars(5500).
❑1,AS owner of the quarterly,or my employees with wages As Meir sok Compensation,
will do the work.andthosmeuremnotkundedaoneredforsak(See.70".Business Required Inspections
and Professions Cade:The Cororecmrs Llttme Law doe not apply m an owner or 9
properly who Wildearimproveethereon.and who daessuchworkhimselfor Waugh his
awn employee,provided mel men Impmwmenu arc notmunded oraRend for Sale.If,
h..,,the building or Improvement is mid within one you of completion.the Cornu.
builder will have the burden of proving mat w did of build or Improve for purpose of
sale.).
0 1.es owner of me property am eulo ivelY co md-9 with licensed cvnaman m
coneWct the project(Sec.7004,Business and Profession Cade:)The Com mor's Li-
cca to Law it=not apply in an owner of pmpeny,who builds or Improwa thereon,ad.
who contracts for such projems with a contractor(s)licensed pursuant an Use Convector`s
License Law.
❑1 am exempt under Sec .B k P C for this Seaon
Data
WORKERS COMPENSATION DECLARATION
I hereby grim under penalty of perjury one of me fallowing declueflonse
❑1 have and will maintain aCenifieskof Comem m ulf-Iasun far Worker`s Compen-
mion.a provided for by SecWn 3700 of to labor Cade,fm the perform.of the
were for which this permit is issued.
❑1 have and will maintain Worker's Comlotudoa I.,As mquired by Secdan
3700 of W Labs COCA.for the Performance of me work for which mu permit IS issued.
MY Warkee Com =6 Wurse nits and Policy number are: -
cuti= i(A" � Policy No.:
CERTIFI •OF2 EMFnoN PROM WORKERS'
COMPENSATION INSURANCE '
(Thu section and hot aeeomplekd if tae permit Is[Drone hundrddoBan($100)
or less.)
1 CenifY mot in the ptorormuoc of time wort for which this permit is Wood.I mall not
employanypersoninanym"rte',wan became Subjectm W rken'Cmnpanutan
Least of CAlim.m.Dale 05)
APPlinent
NOTICE TO APPLICANT:IL eMr ng to cnnme.m or Exemmmn,you,nam"
become subject m the Worker's pematon previsions or me labor Code,you m"I
.7 0 forthwith comply wire tueh p vuinne or Suis permil mall w dcemd mwkcd.
„Z„h CONSTRUCTION LENDING AGENCY
[•n Ihereby AM.met men h•co"vued..lending agency far me perfonnarue of
Ir` > me work fur which this permit Is Wood(See.3097.Civ.C.)
4 IM Lender's Name
i7. z Lender's Address
U 21 comfy that I have red this application and Nm mat the above information is
V. correct.1 agree to comply with all city and county ordinances and sum laws mlaling to
QU building construction and hereby authorim representatives of Suis city to cater upon the
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above-mentioned propcny for inspection purpou.v.
t.4 (We)agree to save,indemnify and keep harmless the City of Cupertino against
fA liabilities,judgments,Costs and expenses which may In any way acerne against aid City /� +�
()z APPLICANT.of the NDERSTANDS AND this
WILLWILL COMPLY WITH ALL N •PO NT Issued by; Date (— /•—l C'
SOURCE L ONS. �n .
Y �-6 Re-roofs
man 11 ucontracmr Dan: T of Roof
HAZARDOUS MATERIALS DISCLOSUR Type
Will W applienl a fumm building Cccupantvom at handle hauardo"material
AS defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Seed.2553x(.)7 All roofs shall be inspected prior to any roofing material being installed.
C]Yu
Will me appR"m or future wilding occupam tree equipment in devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit hanNn"All notes name As te0ned h me Bay Am,Air Quality Management all new materials for inspection.
Dssa7
0 Yeau
I have mal the haudhkamouriats requirements under Chapter6.95 orme Caliror.
nu Health 6 SafelYCade,Sa umu 25505.25533 and25534.I udcnmad muirthe building
does rot nstrcmly hew a mnane mat It u my rupomihllity m n0UIS the pant the
mgcimmenn nest t or of.Cntlins,ar ySignature of Applicant Date
Oerorauth edagcnt Dam All roof coverings to be Class nBa or better.