05100199 CITY OF CUPERTINOk'"e uta+
BUILDING DIVISION PERMIT VCONTRACTORJNFORMATION:
BUILDING ADDRESS: PERMITNO.0 510 019 9
22291 CUPERTINO RD LOT 2
OWNER'S NAME: PERMITISSUEDATE
CUPERTINO ESTATES LLC 12 06 2005
E; SANITARY NO, CONTROL NO.
ARCHITECTIENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
1 Mmby afro that 1 am licensed under provisions of Chapter 9(commencing
sth Sector,1000)of Division 3 often Busiress and Profeubm Coda,and my license is
m inrullforceandenect. REVISION-DINING/FAMILY/GARAGE ROOF
z_ Llcelne LlN sista R563�11 NO NEW PERMIT-IN HOUSE ONLY
�g Dtus_tyara -Conummr QEV6(e
r ARCHITECrS DECLARATION Al CAIT
>f i understand my plana shall he used u public retards
J
k o
Licensed Profcssionel
g OWNER-BUILDER DECe Contractor's
ON
4<I 1 naso .(firm that 11. exempt from dtc Cantrmmr'a License Law for the
E p O following mama.(Saito 7 construct,
t,Business and improve.
de ons Cade:Any city m me county
$tai which mqulrea a permit ro cnmua4 eller.Improve.demolish,a repair my stinum
poor it)its l6aance.also requlns the applicant for uch permit to file u@ned statement
FFF< that he 1.lice..dp rsonsmtolhcprovisionsoftheCommon'sLicenseLaw(Chapter9 Sq.Ft. Floor Area Valuation
S� (commencing with Ston 700(l)of Division 3 of the Business and Pmfassions Code)or
3 Nn he 6 exempt droefran and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant m a civil penalty ofppN Nppr�I�{,,er Occupancy Type
set am than r.hundred dollars(seat). 3M6 616 U 1 / . 00
0 1,u am.of the property,or my..play.with wagca u their role coupe sandon,
will do to work and the auucu ,is not intended mortared for sale(Sm 90M,Business Required Inspections
and Professions Code:The Committees License law does set apply Inan own.of q p
Property who builds or lm pmvea thereon,and who das such work Mmself ar through his
awn employes.provided that such improvements sen not Intended warrants formic.If.
however.the building or improvement is mid within are year of empledon,the owner.
Wilder will have the burden of proving that he did not Mid or Improve for purpose of
salt.).
0 1,as Owner of the property am exclusively contracting with licensed eontnemn in
construct the project(Sec.7041,Business and Profusions Cade:)The Conlnctor's Li-
cense taw does not apply to an mover of propeny.whO builds or improves thereon,and
who contracts for sorb projects with acontracto*)IIce dead pursuant to Ute Contractors
Liccnu Law.
0 1 am exempt under Sea .B a P C fer this mown
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury sen of the fallowing declandons:
ave and will maintain a CeNficate of Consent m self-:mum far Worker's Camper,
n,u provided for by Section 3700 of the Labor Cade,for the performance of the
woh for which this permit is issued.
0 1 have and will maintain Worker's Campenutimn Insurance,ss required by Section
3700 of the Labor Cada,For the performance of the more:fawhich this Fermi,is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cerner.5 rAlf GUAI n Poliry Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Wouaplamd Else permit a foranc hundred dollars(SIW)
or leu)
1 artily that in the performance of the work for which this permit is issued.I shall not
employ any person in my mannerm u m beswne subj.t to the WorkersCompeuation
Laws of Califoon t Data
Applicant '
NOTICE TO APPLICANT.If.after making this Certificate or Exemption,you should
became mbjat in the Wat.'s Compensation provisions of the Las.Code,you must
z forthwith comply with such provision or this permit Nall be darned revoked.
r CONSTRUCTION LENDING AGENCY
I—r I Mmby 4Mm that dart is a construction lendingagency for the performance,of
O: the work for which this permit Is:read(Sec.3097,Civ,C.)
W� Lender's Name
z lander.Add.
U0 I ceNfy that 1 haw read this application and sum thn the shout information is
U,F cartncL 1 agree to comply with all city and county ordinances and sum laws naming to
O V building construction.and hereby w0wrine mproneontatim of this city u,came upon led
k27 shove-menuoncd pmpeny for iupecuon purposes.
(We)agree to save.indemnify and keep harmless the City or Cupertino against
coy pd'g Ibbilities,Judgment,cats and expenses which may In my my acetic against said City
in
U.Z, APPLLICANT UNDERSTANDSf AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE PNS.
12/0610.L Re-roofs
Signaure of Appr
AZAmacw Joan
RDOUS MATERIALS DISCLOSU RE Type of Roof
Will the applicant ar future building occupant store or handle hmarduus material
u de0red by the Cupertino Municipal Cade,Chapter 9.12,and the HcaIN and Safety
Code. C]Y.
�No All roofs shall be inspected prior to any roofing material being installed.
OYu
A I Wh Will the applicant or future building Occupant use equipment.Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
halard..air conuminmu u Jerred by to Bay Area Air Quality Management all new materials for inspection.
ict7
[3 yes OJNu
I have real the hmardousmeterialsrequiremmnu uoler ClupuO6.95 orthe collide.
me HemisB Safety Code,Sectiau25505,2ss33 and 25534.1 orders"thatift a building
des at currently have a mnan6 that it is my nsponsib Inn to muly,the Occupant of the
requirewhich muabcmatpriorwisstmmafacenircamarocmpancy. Signature of Applicant Date
UP 6
owner or themed agent D e All roof coverings to be Class"B"or better