05080137 CITY OFCUPERTINO ' �'�'
BUILDING DIVISION PERMIT ,CON,TRAGTQR TNF ORMta.TIQN =;
BUILDING ADDRESS: PERMIT NO.05080137
21776 CO T?Je-C!Wr)T�'rTJ CIT
OWNER'S NAME: PERMIT ISSUE DATE
JANE PAN 005
E: SANITARY NO. CONTROL NO.
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT FLUMB MECH
0 0 0
30o
-LICENSEDCONTRACnOR'SDEsionof hap Job Description
r� I hereby 0)of that I am f ft Bu i Mer provision of Chapter 9(commencing
a2� wire Section 7000)of Dividers Jalthe Business and Rofeuiou Gads,and mylicense t&
in full to=and effect ADD 3541 LIVING ® 1ST FLR—REMODEL
License cl.a Lk.a 300 ' ( N WALL/MS & LOWER BATH)
Dam Contactor L E
ARCHITECTS DECLARATION
understandI understand my plannshallshall be sand as,public Tamarix
FINu
�p Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby.(Sean on 1 1. exempt from the Contractors A nm Lew for ma JUN .
00 followingmama.(Semon 70 consumer,
Business and ve.dimou Code:Any City simense
$� which mquims•permit m eahNnuet,alter.improve,demnit&h,on repair any suuetom
fa prior m its issuance,also requires the applicant fornsch permit m file a signed statement
gs<
that he is licensed pursuant m Ne provisions of the Contractor's Lican.Lew(Chapter 9 l C Val�'aT.il)T4 0 O 0
G o (commencing with Section TODD)of Division 3 of NC Buioc.and PmfesdonsCak)of
33$ that M is exempt therefrom and Ne but&for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofP Occupancy Type
not mon Nan Ow hundred dollars(55001. 35617047 . 0 0
0 1,as owner of t e property,or my employees with wages u their sale compensation,
will do Newark and On structure lermHntended aoffend formu(San.7044,Budnrn Required Inspections
and Frofestou Code:Tim Communes Liceve law dots ml apply m e ns en owner of q P
propeny who builds or i mprow thenars,and who docs such work him.l f or through his
own employees,provided that such improvements me Out mended aoffered forsah-.if.
however,the building or Improvement is mid within ane year of completion,the owner.
Wilder will have the burden of paving that he did Out build or Improve for purpose of
ole.).
ot 1,u owner of the propenY,am exclusively conuaming with licensed eanbaeton to
construct the protect(Sec.a an wner of and ny wh Wilds
Code:)The Cmumton',and,
ewe law coca not apply m an owner of pmpmty who Wilde or Improves mmmn,and
who mnuaw.for each projects Os
m+withsconcm(s)Ilecued pun.ntmNe Contractor,
Lken.Lew. "
El1 em esempt under Sec. .8 k P C for emn
bN t3 .u •,e' /6 Os
Own" h Data
WORKERS CO 4PENSA ON DECLARATON 0�-7 fP
1 hereby affirm under penally of perjury one of the following declsn0ou:
Morand will maintain a CenlOamm'Con.m to self-insure for Workers Compren- _
.tion,an provided for by Section 3700 of the labor Code,for Nm performance of me
work for which this pcmm is issued.
0 1 have and will maintain Warker's Compensation Insurance,as,required by Section
3700 of the Labor Cale,for the performance of Ne work for which this permit Is Issued.
My WorkcM1 Compensation Insurance caviar and Policy number me:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPFNSA71ON INSURANCE
(This section need not he completed irte permit is foranc hundmddollen(5100)
orlaa.) W OWALp 6F 6typrQL
i certify that in me perfnrmance of tan wart far wh h Nis permli u ivaod.I shall nm
employ any person
rnia. any ann•/! a oat jun'Compensation
Laws of California. mDem
Applicant
NOTICE TO APPLICANT:If,after making Nle Ccni am of&caption,you should
become subject to the,Workers Compensation provisions of tan lata Code,you moss,
.J O forthwith comply with such provish u or Nis permit shall be deemed Malmo.
.N~., CONSTRUCTION LENDING AGENCY
F (hereby alfa tNhlMm is a eambection lardingegercy l'm du performance of
C$.tea the work for which this permit B issued(Sec.3097.Civ.C.)
0J Q Us&,',Name ,
z Lender's Add.,
U p 1 certify that I have read this application and sum mat tan above information 4
11,!' mrrock i agree to comply with all city and county ordusacs and sum Is"zeiatint to
C)rV' Wilding construction.and hereby simonize representatives of this city m now upon the
W ahove.mantloned property for lupecumt purpuea
gy (We)agree in love,indemnify and keep harmless the City of Cupertino egaiut
h liabiiides,judgmeenu.cesu and expeuu which roar'iWanaryaccmRegalestsaliCity
V 7 in couequence of the gnthtnt of mu pcmui6 ON TXeBh1LF OT C4lMr•IL
rte• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N NP Nr Issued by: Date
SOURCE,gL� ATIO B
�G ° Re-roofs
Sib u ofApplicantlComeem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant nom or hendlc hounduu material
as dcMcd by the Cupertino Municipal Code,Chapter 9.11.and the Hcalth and Safety
Code,Semon 15532(a)7 NO No
All roofs shall be inspected prior to any roofing material being installed.
0y.
Will the applicant or future Wilding Occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haaarcous air contaminants u dellned by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
GYa KNo
I have mad the harudws materials requirements under Chapter 6.95 of the CxWor•
nia Health A SafelyCode,Sections 25505,35533 and 15534.1 understood mu if the Wilding
does not currently Neve a arta mu it u my responsibility in notify the ox.mar l of me
mgwm ha W t�haof.CmtDcama Signature of Applicant Date
gfid ns
owner ar mmamed. and .F CXA4LC.1`L Data All roof coverings to be Class"B"or better e