03080181 CITY OF CUPERTINO `" a '� �% �'� 73 '^jYg�^ '^'•`^
BUILDING DIVISION PERMIT VCO R. RJNFORMATION ri
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BUILDING ADDRESS: SAMUEL CONSTRUCTION PERMITNO03080181
2445 CUPERTINO RD
ER'S NAME: 3427 FLORAVISTA AVE. PERMITLSSUEDATE
SUNNY VIEW LUTHERAN HOME 10/27/2003
PHONE: (408) 249-2828 SANITARY NO. CONTROL NO.
ARCHITECTIENGINRER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!00 rom that
order Provisions
1z 1 hereby affirm that 1 em f licensed i n ass prevision ofs Cods. 9 my license
Job Description
Mwith ltf'-a 7(%d(i(f Division 3af NC Busi aaM Prafcssiuru Cods.mtl myliccnac is
�w nfull force an f
jgz
Lice KITCHEN e,g S'Co1s772. KITCHEN ADDITION/REMODEL (280 SQ. FT. )
Dam - Camtamar n 4a4Aa!- DOES NOT INCLUDE PLBG/MECH/ELECT
e ARCIi1TEinscolDECAI xuda ORIG. #02060159 WAS EXPIRED (SEE NOTES)
C ON
1 undcr¢tand my plans shall he used EC TI rda
J
cp� Licensed Pm(cssional
a OWNER-BUILDER DECLARATION
? I I hereby affirm that 1 am exempt from the Comracum'¢License Law for the
COO (ullawing reason.Section 703 1.5,Business and Professions Code:Any city or county
$ which requirca a Permit to construct,Sher,improv,demolish,or repair any nrucrem
y prior to its issuance,also requires the applicant for such Permit to file a signed statement
]�m< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
uF$ (commencing with Section 7")a(Division 3 of the Business and Professions Cook)or .75000
.� Ntherefrom and he is exempt therefroand the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fon permiuubjects to applicant to a civil Penalty of APN Number Occupancy Type
nos more than fiw hundred dollars($500). 32615124 . 00
L u e work.and
pmpetty,m my cmptoycea vim f...
sok compenation,
will Professions
and the he Structure Livedproffered Lawdfontapplyto an,Business Required Inspections
Sod property
who
obis Code:The ws tacrefs License Law dons not apply m an owner of q P
own erty wyees,prism ed that
lherrom and who does wink himsedfor offered
his
own theeuiprovidedmauochimprovementsarcnot Intended orDeemted for axle.If,
however,illhaw tiebrimprovementg Sold wiminot year of completion,the owner-
builder will have ma burden of proving ren he did not build or improve for purpose of
ole.).
Cl L as owner of me property,,B exclusively ly convecting with licensed mrsecoem to J /!
consumerLw does nal i Sec.70x4,Bvincix sod dy whoom ds or I pro Contra on, rad
cove law docs naupplr a an Ower of property who builds or Improves thereon,and / -
whenseLacuforsuchpmjectswitheconvecmr(s)liwnsed pursuant mthe Contncmh u
License Law. •-�„
Q I em exempt under Soc. .B d:P C for this reason
•r Date
WORKER'S COMPENSATION DECLARATION
I hereby arm under penalty of perjury,am of she following declarations:
❑I new and will maintain a Cenificne of Covent to self-insure for WorkefaCompen-
station.as provided for by Section 3700 of the labor Code.for the performance Of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as requited by Section
3700 of the Labor Code,for the Performance of mpwork for which this permit is issued.
My cre'S`Compensation Insurance cam Policy number are:'
Policy No.:IT Ig 17 S8_
CERTIFICATECOMPENSATION 7INSURA CON FROM H INSURANCE //
(This action need not becompleted KIM Permit is forov hundred dollars(SI010
or tea.)
1 certify that in the performance or the work for which this permit is issued,I shall not
employ any Person in any manner so a to become subject to the Workers'Compensation
Laws of Celiromia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifci a of Exemption,you should
become subject to the Worker's Compeasstian previsions of the Labor Code,you mon
7zM
rowi In comply with such Provisions or this Permit Shall W deemed revoked.
Zg CONSTRUCTION LENDING AGENCY
1 hmchy afrvm Net mere Is a consWdinn lending egemy torthe perfurmonce of
Y. > me.,it for which this permit is issued(Sec.3097.Civ,C.)
QLendces Name
z Lender's Address
Q 1 certify that 1 have mud this application and state that the Show information is -
y Fcorrect.I agree to comply with all city and county ordinances and sure laws halting m
C) building concoction.and hereby aumorin,representatives or this city to cnkr upon be
Uamon purposes.
hovcemiuned property for inspection
(We)agree to save,indemnify and keep humless the City of Cupenin0 ageiw
rA liabilities,judgments,cue and expenses which may In any way Scene agadvunid City
;)z in consequence of the graining of this permit.
APP (CANT UNDERSTANDS AND WILL COMPL TH ALL NON-POINT Issued by:3 Date
SOUR@EREGULATI NS,
R—Va. — 1`01Z 7 Re-roofs
Signature orAnVCon r Dae
ARDOUS MATERIALS DISCLOSURE Type of Roof ,
Will the applicant or future building occupant store or handle haeuduux material
defined by the Cupertino Municipal,Coda.Chapter 9.12,and the Health and Safety
Section 25532(e)?
0 yNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rmure buildinguccupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants a dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
Disvin7
❑Yes AkNu
I have mud the haaardnus materials requirements under Chapter 6.95 of he Cali foo-
nia Health d:Safety Code,Stations 25505,25533 sand 75531,1 UnearAad that if the building
docs not curremly how a tenant,that it is my responsibility m amity the Occupant Of d¢
requirements which must be met prior to issuance of a Certificate or OccuPanry, Signature Of Applicant Date
6t,}i 5aa+�wt_L /aa/271e'i All roof coverings to be Class "B" or better
Ow tar authorimd agent
Data