03110071 CITY OF CUPERTINO '"' >� �^• + `*
BUILDING DIVISION PERMIT CONT"CT(O-R INPORMATIO,N `
BUILDING ADDRESS: PERMIT N0 0 3 110 071
10625 CORDOVA RD
" ER'B NAME: PERMITLSSUEDATE
20Z HO 11/14/2003
NE: SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECII
G7 0 0
+00 LICENSED CONTRACTOR'S DECLARATION ith S )obDescri [ion
CC s0 I touchy affirm that 1 am licensed under provision of Chapter 9(commencing p
eP2 wection? f0ivlaian 3 ofthc Business and Professions Code,and my is
in full Bruce dance ADD 36 SQ. FT. /ENCLOSING EXIS . FRONT ENTRY PORCH
)SZ_ Lmen7.�,
Lic.a
=tee Dateeentreetor & NTERIOR REMODELING
ee 11 RCHI CrS D RAT
C w a desm s u se public mcnrda "1
J
yu. Genu at Igvr^"I
h g Oat I am CU Efr DECLARATION s
<I 1 h... al'Brm that 1 em cx In from the Contractor's License Lew for the ns'Sla�• 4 )
O o following moron.(Sccuon 71131.5,Busincas end Profession Code:An city.9mmumY
which rtyulms a penis m cnnswet.aper,improve,demolish,or re r any.miuctuol
�i6 prjonmits issuance.also mquims Bec applicant to mchpermi0o files I ned summcns n,
2x mmWisliccnseJ'ma "uolhepmvisionsrftheConvacturiLittnse w(Chepmr9s `' /Sq? FtfFlootArea Va1H$T�8000
2Fsh (commencing with Senimn700a)of DivisimnJnhhc Businem and Prof inn Cixle)ur
BOB he u exempt therefrom and the basis for the alleged exemption.A yvlb iRlim of A\ 1�1
Section 7031.5 by any applicant for a permit subjects Ne applicant to a i it pantry of
not mom than five hundred dollars(S500). er Occupancy Type
❑Las ownerefthe pmpeny,ar my employceswilh wegexssdseir wle ion,
will do the week,and the swcme:isnot intended or offered for sale(See.70".Business
and Pmfemions Code:The ConoanoYs License law does not apply to an owner of Required Inspections
propeny who builds or improves thereon,and who doessuch work himself or through his
own employ=,provided Nat such improvements see not intended Or offered formic.IL
however,the building or improvement is sold within am year of cmmpicumn,the owner
builder will have the burden of proving that he did not Wild or improve for purpose of
colo.).
KI.as owner of the pro
geny,am exclusively convecting with licensed conuactots to
onsuuct the project(See 70aW,Business and Professions Code:)The Convector's Li. .
cone law docs not apply to an owner of property who Wilds or improves Become,and
who contracts for such projects with a convmtoms)licensed pursuant to the Contractor's
License Law.
❑1 vex exempt under Sec. .B k P C for this omen
er Data
WORKER'S COMPENSATION DECLARATION
1 hereby a(0m,under Penally or perjury one of the following declarations:
❑I have and will maiming Cenificamof Conssnuoseff-hom eforWorker'sCompen-
mrmn,as Provided for by Section nam of Be labor code.fire the performance of me
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inursna,as required by Scedon
3700 of the labor Code,for the Performance of the work for which this Permit is issued.
My Worker's Compensation Insurance eerier and Policy number am:
Cartier, Pol icy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
obis scrim need not W comple¢J if ix,Permit is(mane hundred dollars(SIM)
or @m.)
I ceniry Out in she perfmmance of she work for which this permit is issued.I slist)raw
employ any person in any manner sex Is in Wcume subject to me Workers'Compensation
Laws of Caltromia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifical,or Exemption,you should
become subject in the Worker's Compensation pmvistons of rhe labor Code,you mum
.,O ruMwido comply no such provision or min Permit sha116c deemed rxwkcd.
z
`Z'
CONSTRUCTION LENDING AGENCY
I hemhy nfO,m Wt mort is a embour tin lending tummy nor 1M performance of
> the.,it m,which this Permit a iamed(See.3a9'f.civ.C.)
A Lender's Name
z Lender's Address
J 0 1 agree mat I have reed this application and mm¢ren the shove information is
0 U toren.I ague to comply with all city and count'ordinances and muse bsnt elating m
rJU building construction.and hertbyauthmt000ses. lieu of this city to enter upon ae
{17 aborR�F
peny,rte inpecuon pueposea
4. mw.indemnify and keep harmless the City of CuPeninO againI
.w h liab .rose and calcines which may in any way tame against mid City
UZ in cgranting or this permit.APRS`rANDS AN LY WITH ALL NON-POINT Issued by: Date
SOIONS
e-roofs
sere ar Onsru r Da
HAZAR US MATERIALS DISCLOSURE Type of Roof
Will me epplation serf building Occupant store or handle havallous national
m defined by the Cupertino unicipal Code.Chapter 9.12.and the Health and Safety
Code,Se❑cYoens 25532(a)7 0� All roofs shall be inspected prior to any roofing material being installed.
Will the applicant m future building occupant use equipment or dsvima which If a roof is installed without first obtaining an inspection,I agree to remove
cmR havudful air conuminams u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
O Yes Flr_�
Iha))final the has Niwsmaorialsm u' sunder Chap¢r 6.Y5 of the Califnr-
hisHeal &Safetycod ccuon255o 3aetzss dersmnd the sena Wilding
does n co m it,hav v�ex9a tis my respenihitity m ufy rhe occupam of me
mqui enr m bepC. borwtssmnceafaccodIma orok"Opmcy. gnature of Applicant Date
w fur ori'rtd age am
All roof coverings to be Class"B" or better