06060084CITY OF CUPERTINO
OR
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
MICHAEL MOORE
PERMIT"°'06060084
22350 C112ERTTNO RD
OWNER'S NAME:
PERMIT ISSUE DATE
ft MICHAEL MOORE
12/14/2006
NE:
SANITARY NO. CONTROL NO.
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
pmv.. of Chapter 9 (cemmcncing
ffirm t 1 am licensed underisi
1 hareby atha
won Section ]Oce) of Divirum 3a(the Busineuand Pmfessm. Code, and mylici nee is
in fall to= and effeam
ADDITION 1233': 3 BEDROOMS, FAMILY ROOM
License Class Lk. Is err
Dan
1 BATHROOM. REMODEL KITCHEN -1 STORY
ARCHITECTS DECLARATION
_
I understand my plans shall he used as public meths
Licensed P.fmcd... I
OWNER -BUILDER DECLARATION
I Wreby aRrm Nal 1 em a.p( from the Canrnmues License Law for the
> following reuon. (Section 703 1.5, Business and Pmfectlo. Coda: My city or county
which requires a Permit to construct, alter. Imp.w, demolish, or repair my structure
! prior n its issuarce. also requires tWapplicam Tor such permit'. file asignN statement
r
Sq. Ft. Floor Area
Valuation
thathculicenedpursuanuodmprovisionsofdxConuacuxhlbxnxhw(Chapter9
(commencing with Such..( ) of Dwism.3 of the Busi.and Pictures.. Code) or
$284468
that he is exempt thme(rom and the basis for the alleged exemption Any violation of
APN Number
Occupancy Type
Scenes 7031.5 by ury applicantfar a permit subjects the applicant to a civil penalty of
nor... Nan few hundred dollen (5300).
❑ 1, u owner of die property, a my employe. with wags u dery sole compensstion,
R
-8 -
Required Inspections
will Profewark. Business
etnmuuresI ed caraw,
does
law, does ret apply if an aw.r
Cade TW Canmcmrs so
and Code,7ba
q P
pProf roperty is
who Wildsarimprawsthand daensuchwnrt himselforthmugh his
br who
imporwdwho
own am impmvementserene
own dedoraneredforsw.-
wer.Oca,proWdedthatmoh
year
hAlcher Ne WildinLarimp.vement us.lde did a.Yearofimrovefa.Neowm-
Wilder will haw dm When of pmvine that k did wt dub m improve for purpose of
nle.).
. s owner of the property. am exclusively contracting with licensed commence, to
w.trm the pmKct (Sec. 7014, Business Pad Hafcssi=Cade:) The Commmats U.
«me law dour not apply in an owner of property who builds or improves the.on, and
who comment for such projects with a contrazmr(s) licensed pursuant to no Contractor's
Lice.e law.
C lam SecB&PCformetramon
�
Owner t I V ` 1M-•�� Date
- - WORKER'S COMPENSATION DECLARATION
1 thereby aRrea under penalty of perjury, one of the following danlantiom:
1 hero and will maintain a Curti of Consent in self -insure for Water's Compton -
and., m pmvidcd for by Section 37M of the Labor Code. for ita Performance of the
wear, for which this Permit is issued.
❑ I ban and will maintain Worker's Compe.mion Imunnce, as required by Secium
3700 of Ne lobar Code, for the Nrform. of the work for which this; permit is issued.
My Warice, Compemztiome lenience carrier and Policy number-
Carier: Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(This section nand not be completed if the permit is f.rome hundred don. ($100)
or less.)
I ceoify, dust in the pufome. of the work fm which this Permit is issued. I shall not
employ my permit in any manner se. to became subject to the Wafter} L-rmper4adan
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making Nu Certificate of Exemption, you should
become main" as the Wmlmr's Comp oustion pro,iuoess of the labor Code, you .tau
' forthwith comply with such Provisioes or this permit shall W deemed nw.kcd.
j CONMUCT10N LENDING AGENCY
• I hereby union this them u a construction lending agency for the peNonnan¢of
' the work for which this permit is issued (Sec. 3091, Civ. C.)
Lowlefs Name
Lender's Addrea
I certify than 1 hon read this application and ata, this the above Ofomtatimt is
' correct. I agree m comply with all city and county aNinuhces and sum laws relating to
building construction, and hereby auth Trio, o presemativcs of this city in cnmr upon tW
ahovc-mcnuomd Pm, c for inspection purposes.
I
(Wo) agree to save, indem fy and kap humorkss the City of Cupertino against
i rt es may In any way accrue against said City
dgmcthe cosuandOf
incomandu
inconsequcncc of the granting.! Wspermit.
this ant.
' APPLICANT ND RSfANL�S,pND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR 1I,A ONS.I I/)
Re -roofs
Srgnuurt of ApphcaHAZARmor Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Willy or court ad ileon h material
e.
as t e Calaminent
by the Municipal o
Calamine MunitlPal Cadc. CTapmr 9.11, and the Health and Safety
Chapter 9.12, Health
nn.SeP
32(s)l
c.Ue. Section 2ss3z(ap
❑ res al"r—
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device which
If a roof is installed without first obtaining an inspection, I agree to remove
t h aT rdom air contaminants u defined by the Bay Arca Air Quality Management
all new materials for inspection.
D istr ictY. Bye'
I is. read the locan deas..data rtqui..cnu under Chs pmr6.95 ofthe Cali(or-
nizHcalth& Safcty Cade Scetierv]5505.25533..125534. 1 ura mond dwifthe Wilding
dc. rut c ly ave a erne t, this it is my rtspomiM1ility nodry the occupant of the
¢quirt. icwmutW t rionuissuan faamofoccupsecy'
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner s mthmi.d.licrK Dam - -