04100094 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,C,ONTRACTQR INk'ORMATION „,,
BUILDING ADDRESS: SILICON CONSTRUCTION PERMITN004100094
22245 CUPERTINO RD
OWNER'S NAME: PERMIT ISSUE DATE
DE ROSE CHARLES AND KAY D 1900 OLD MIDDL
JE:
SANITARY NO. CONTROL N0.
(650) 938-9600
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
L0, LICENSED CONTRACTOR'S DECLARATION
m u C I hucby affirm WI 1 am licenud under provisions of CTapscr 9(mmmcncing Job Description
�Zw with Sadon )of Di "onJof the Basin Pmfessiune Code. nd my license is
�nr c^I to. yit arfecl EMERGENCY WATER DAMAGE REPAIR
Sec,H❑ Da¢ t Canuacmr (YA fM<_ C /
A SDECLAR.UGN
1 undcrsu ons s I M pts Ifc rtcmds
Jso
3a. I-Mcm,51Professions
OWNER-RUILDER DECLARATION
i I I hereby affirm that
1 om exempt from the Conbanar's Liecnse Law for the
p O following mason.(Section 7031.5.Business and Pvfeaduv Code:Any city or county
r m which acquire a Permit or c WUUU,alter,impmw,demolish,nr tepair any Stmmam
't—'^ prior In its issuance.also res,irrs the applicant for such permit Ric a signed statement
��< That he is licensed PmxUrL tuthc PmvUmrrx of the Contractor's Li¢nm Law(Chapmr9 Sq. Ft. Floor Area Valuation
n�D (commencing with Section RX0)of Division 3 of the Business and Professions Cook)or
i $
that he is exempt thcrtfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant(a,apcsmi,subjects the applicant m is civil penalty of e 0 Occupancy Type
not mom Nan Bw,hundred dollars(23007.
❑1,v owner ofthe pmpcny,or my employees with wagu u their sole compenudon,
will do the work,and the structure is not intended or o@red north,(Sec.7W.Business
and Profusions Code:The Commemrs Licata Law does not apply m an owner of Required Inspections
propcny who buiidsor improve themon,and who doessuch work himselforthrough his
ownemployces,provided that such improvements art not intended or catered for Sale If. '
howevu.the building or improvement is Sold within one year of completion.the mance.
bcove -
builder will dm burden of proving that he did not ddb ryox or improv for puof
sFIN ALE
ale.).
El 1,as owner of the property,am exclusively contracting with licensed contractors m
consumer the pmjcct(See.7044,Business and Profusions Code:)The Contraemr's Li.
cove Law does not apply in an owner of property who builds or improve thereon,and FEB z
who concocts for such projects with a eonlOemr(s)licensed purxuam m Ik Contractor's v1006
Lie".UW. C
E]I an exempt under See. ,B A,P C for this moan 1y�p
Owner Dam f{ a
WORKER'S COMPENSATION DECLARATION40 {iy "
b r ' "•x'
1 hereby arcro under mostly of perjury am of the n
following declesions: y'Su '= �—
❑1 haw and will maintain aCcnifinm of Consenuo self-insum for Warkers Compen-
sation,is pmvided for by Section 37M of the Libor Code,for Rte performance of the
work for which this .it is issued.
❑1 haat and will maintain Worker's Compensation Insurance,as sequined by Section
3700 of the labor Code,for the a formavc of the work far which this permit is issued.
My Workefs Cnmpensadon Immom.carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiasectian need not m completed time permit is(aronc hooked,10L.(SIM)
nr less)
1 certify N t in c performance of the work for which this permit is issued.I shall not
I any on inne,so an me subjthe Workers Compenndon
lUwSDf Califo
plic I
fl TO AP :If inl'R3Cenificare of Exemption,you should -
subject m e Worker's ComPcvnian provisions of the Lamm Code.you must
.J O foMwith comply with v such orwisinor this permit shall be deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
�-- � I hemby affirm that them is a construction lending agency for the performance of
C dm work fur which this permit is issued(Sec.3117.Cr,C.)
Le!y Lender's Namc
U O I certify that 1 have read this application and sum din she above information is
{T.(•^ contet.1 agree to comply with all city and county ordinances and Stam laws relating to
Q U building construction,and hereby authorin mprnscmadve of this city to enter apes the
} ahovcmentionel pmpeny for inspection purposes
(We)agree to saw,indemnify and keep humlees the City of Cupertino against
Hrq liabilities,judgments,costs and expenses which may in any way accom against win City
U z AP nsequcnecUNDof c grand NDSIhis AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 6G /
SOU I ONS.
az -o Re-roofs
urae Op'c _HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or future building occupant stem or handle hvallous material
M defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safety
code.spYu ec Yea zss3z(a)7 No All roofs shall be inspected prior to any roofing material being installed.
G
Will the applicant or ffuuttuure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil haeadsus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District,
❑Yea Kr'Nu
1 have mail the havamous materials requirements under Chapter 6.95 of the Califor-
niaHchh&Safcsy ccuom25N,S255J3wd25534.1undcrsundthnifthe hdilding
docs mi oily haw -m L the il'u my nespansibinty m Unity Me occupant UI the
regam
imc had, Win priortuisomencofaCensficateo(Occapanty. Signature of Applicant Date
Ownerifadt riaca agent � � y All roof coverings to be Class"B" or better