04040096 (2) CI'T'Y OF CUPERTINO *^ "' ;U"?k
BUILDING DIVISION PERMIT ,C-QW,RA TORI FORMATION ,
BUILDING ADDRESS: PERMIT NO.
04040096
M'S NAME: PERMIT ISSUE DATE
ONE: SANITARY �AtOL N0.
CHI'IECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0, LICENSED CONfRACIOWSDECLARATION lob Description
iUWC 1 herby affirm that I am licensed under provisions of Chapter 9(commencing
to wto ith Scctian7000)of Diviaion3of Ne Businm=dProfessions Code,andmyliccnwis
_Om in full forte andcAcwu 7.�7$S2
,Ljz Licens�e I)tis 4/ tie.« - REMODEL 2 BATHS/WATER HEATER
o�c DBN 11I-T � comaenm. s/ CONTRACTOR: JEFFREY MILLER, GENERAL CONTRACTOR
?ai'J' ARCHITECTS DECLARATION
U 1 undersand my plans shall he used u Public records
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby aMo.Nat 1 am exempt from Use Contramorn License Law for the
oO following mason.Section 7031.5,Business and Professions Code:Any city nrcounty
which requires a permit to eonsuucL a[mr.improve,demolish,or repair any Structure
prior w is Widum C.also Hui the applicant for such permit to rile a signed satCment
IhathcislicenscapunuanItobeprovisimuofOcContractor'aLicenslaw(Chaper9 Sq.Ft. Floor Area Valu �8000
Ct (commencing with Section 7")of Division 3 of the Business and Pmfeadona Cod.)or
Nat he is exempt therefrom and the tresis for the alleged exemption.Any violation of
Section 7031.5 by a"applicant for•permit subjects the applicant to a civil penalty of A11N Number Occupancy Type
not more Nan five hundred dollars(M).
0 1,u owner of the property,or my employe.with wag.u their role Cooperation. 32637010 . 00
will do the work and Ne swcture is not hoarded or offered forsake(Sec.7W.Business
and Pref.sims Coda:The Contracteres a License Law doao,apply inan own.of Required Inspections
progeny who Wildsm improves harem.and who doessm),work himself or through his
own employees,provided thatsuch impmsemena art not immodest orolfered for ale If. # /T
however,the buildingor impmvemem is sold within one your ofeempktion,the canter, 11�� p
builder will have she burden of proving that hC did not Wild or improve for purpose of D
sale.). Jt
1 V�
0 1,u owner of she pmpcny,am exclusively contracting with licensed contractors m J UL 9«� 9
construct the project.(Sec.70da,Business and Professions Code:)The Contractor's LL Ase► [003
come raw does not apply load owner of property who Wilds or improv.thereon,and Y
who contracts for such pmjeca with a CenorM or(s)licensed pursuant n the Contractors'
Law.
ra
0 ®/py`
larm exempt under see .Bh PCfor this moon ee ay�
Data
WORKER'S COMPENSATION DECLARATION
1 hemby salon under Penalty of perjury ane of the following declarations:
I have and will maintain a Cenifam of Consent a self-insum for WurkmrsCompen-
satiaq u Provided for by Section 37M of the labor Code,for Ne performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,u required by Secdon
7110 of Ne Labor Code.for the performance of the wort for which this Permit is issued.
My Workers` Compensa.tion Insurance canicr and Policy num 'a����
Cartier.ATAIr A" Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scaion read nm Ise complcocd if IK pmmit u forure hundred dNlars(Slip)
or less.)
I certify Nat in the Performance of Oc work for which this permit u issued.I shall not
employ any person in any manner so as to become subjeCt an the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,afar making this certificate of Emri you should
become subject a dm Worker's Compcmnion Provisions of the Labor CMC,you muse
.J 0un
fuwith comply with such provisions m this gcrmit shall be deemed revoked.
Z o CONSTRUCTION LENDING AGENCY
[-+'4 l hereby a0fren that Mete is a ormwetion lending agency for the gerfuomance of
a 7 the work for which this permit is issued(Sec.3097.Civ.C.)
Ia1 I.C.Os's Name
(L fender.Address
U 0 1 certify that 1 have mad this application and some that the above information is
U. F-' COHCCL 1 agme to comply with all city and county ordinances and sax laws relating to
0 U building convection.and hereby MIM11MrepoaenWisas of this city to enter upon the
>a ISI above mentioned progeny for impaction purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupertino against
F' N liabilities. cigmcnu,co adexpcm.which may In a nywayaccmcagaimstsaid City w
U z incomes, w o tinge( 's permit.
APPLIC U ER AND NO WILL COMPLY WITH ALL NO OI Issued by: Date
SOUR
� Re-roofs
ngnuur o p is ZARUCOUSMATERIALS DISCLOSURE Type of Roof
Will NC applicant or future Wilding occupant store or handle hmardous material
defined by the Cogent.Municipal Cee.Chapter 9.11.end the Health and Safety
e.Seedmn 25531(.)? All roofs shall be inspected prior to any roofing material being installed.
0y. W.
Wise thea applicant or mare Wildin oceu ant use tordevices which If a roof is installed without first obtaining an inspection,I agree to remove
pp g p aAirQ
emit haarstnus air contaminants u defined by the Bay Area Air Quality Management all new mater: for inspection.
District? ��s///
O Yes Iy Nu
I have mad the hao mfous materials requirements under Chaptcr 6.95 of the Calder-
%.C'
Safety Code,Sad 25505 25 25534.1 mccoaMdtudde,Wilding
ndy •e Out it is my ruspomibility ta any de amu ant of dewhie IPrim.i5suseccofaCcnifcamafOR ,SI a O ,plica Diad
ye
o m nvcdasent as All roof coverings to be Class "B" or better