04060042 CITY OF CUPERI'INO 4"',
BUILDING DIVISION PERMIT .�CONTRAC OR INFARMATION:,�
BUILDING ADDRESS: PERMIT N00 4 0 6 0 04 2
OWNER'S NAME: PERNUTISSUEDATE
DOYLE DAVID
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
noes LICENSED CONTRACTOR'S DECLARATION
C 1 hereby awl.that 1 am licensed under provisions of chapter 9(commencing Job Description
w with Section 780O0'Division 3ofthc Busincesend Professions Cmaand my Rich.is
3h in mu mac anaerren. ADD 685 SQ. FT. (FAMILY/BED/BATH ROOMS)
p v�z License Class Lk.N
s;, Dale Cast.,
°££,i ARCHITECTS DECLARATION
C a I understand my plans shill In said es Public records
J0U
u.to Licensed Professional
or
OWNER.BUILDER DECLARATION
+� 1 hereby affirm Nat 1 am exempt from Ne Co,nnor's License Law for the
i p o following mason.(Simian 71131.9.Business and PafcvsmiCole:Any city county
K0000
which requires a Petmit m cnrtswct,alma improve,demoll issh,nr repair any trumurt
an
prior an its issuance.also squires the applicant for such Permit to file a signed mlemcm
xx< that he is licensedPunuanuomeprovisioesoftheContractor'sLicens,Law(Chitmer9 Sq. Ft. Floor Area Valuation
�F$ (commencing with Section 70(10)of DivisionJnf lM1e Business and Professions Come)or /
y
that the is exempt therefrom and pne baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 MNQ4"er0 0 Occupancy Type
not mom Nan five hundred dollars($500).
O I,u ownerof the property,or my employees with wages as their sale compensation,
will do Ne work and the strun,e isnot intended or offered for sale(Sec.7(44,Business
and Prefusisa Code:The Contractor's Lioness law docs not apply to an owner of Required Insp Cop/
propeny who builds or im proves thereon,and who does such work hi,self or through his
own employees,provided that such improvements art not intended oroffenA forsals.if.
however.the building or improvement is sold within One year ofcomPlenon.the owner.
builder will have the burden of paving Nat he did not build or improve for purpose of
sale.).
1,as Owner of the property,am exclusively contracting with licensed centimeters to
c awn the project(Sec.7044,Business and Professions Code:)The Contractor's U.
comas Law does not apply to an owner Of property who builds or improves thumon,and
who contracts for such projects with a concomitants)licensed pursue,to the Contractors
License Law.
❑lam sae pounder Sec. B&PCforthisreaan
as
WORKEit'S CS-4 b1ON
I hereby affirm under penalty of perjury one of the following declarations,
.have and will maintain aCenificam of Comma self-insum for Worker's Compere
on,as provided for by Section 3700 Of the labor Code.for Ne per/omu,c of the
work for which this permit is issued.
❑1 ban and will maintain Worker's Compensation Insurance,as mi,mcd by Section
37W of the labor Code,for Ne performance of the work for which this Permit is issued. -
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Paliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mosse,inn need oat xcomplemd time Permit is foronc hundred dollars f$100)
1 certify that in Ne perfonnenee of Ne work for which this permit is issued.I shall not
employ any person in any manner so as m become subject.the WmIceri Compensation .
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis C.mBcate of Exemption,you should
become subject to the Worker's Compensation previsions of thc labor Code,you must
.J 0 forthwith comply with such provisions or this Permit shall x deemed revoked.
Zr4 CONSTRUCTION LENDING AGENCY
[•+� I hereby affirm Nat there is a consuuclinn lending agency for the Performance of
ai
in,work for which this permit is issued(Sec.3097.Civ.C.)
U] Lender's Name
lender's Address
�z
U Q 1 ttnify that 1 have read this application and scale that the above information is
D. H
Correct.I agree to comply with all city and county ordinances and mm laws rel,ing to
�U building construction.and hereby a,home repmacnunves of this city to enter upon the
C above-mentioned progeny for inspection f ugnsba
(Wc)agree to save,indcmnl ry and keep harmless the City of Cupertino against
fn liabilities,judgmmot,costs and expenses which may in any way aceme against said City
U 'Z in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 CC EGULATIONS. ?/ZV
'J�j 98 D Re-roofs
are fApplic.VConuacmr —a Date -
HAZARDO MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant sem or bamk havaidous material
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and Ne Heads and Safety
Code,Section 25532(a)?
[]Y. Nu All roofs shall be inspected prior to any roofing material/big installed.
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
M1aaardous air contaminates as defined by the Bay Arca Air Quality Managcmcm all new materials for inspection.
lricR
C]Yea I�NO
I have mad the haaarelous materials requirements under Chapterti.95 of the Califor.
nice Heeut&SafesyCose,Stench,25505,25533 and 25534.1 under and thatif the building
docs not c dy has a m ant.Nat is h my responsihiliry m nosily Ix occupant of Nc
meal me whichmlktx nor on mofaCertificate orOccupancy. Signature of Applicant Date
thorizcd agentu
All roof coverings to be Class "B"or better