03100184 CITY OF CUPER'I'INO '^; 4P `
BUILDING DIVISION PERMIT CONT,R ORtINFORMATIONt
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BUILDING ADDRESS: SAMUEL CONSTRUCTION PERMITN003 0
22445 CUPERTINO RD
7ARCUITECTIENGINCER;
R'SNAME: 3427 FLORAVISTA AVE. PERMIT ISSUE DATE
SUNNY VIEW LUTHERAN HOME 10/31/2003
E: — SANITARY NO. CONTROL N0.
BUILDING PERMIT]NPO
BLDG ELECT PLUMB MECH
0LICENSED CONTRACT'OR'S DECLARATIONI here y erre that 1 em littrtsed under previa a of Chkp¢r 9ltmmmcaing Job Description
tion )ofDivisionJofthceusinesxen uion,Coec,anemyecenscn PLBG ELECT MECH
t<6 In full three efrect.
n rz License G. Lie.« S�S�-7 7 "y / / .
Dae Caomecm (PERMIT #03080181)
y£ ARCHITECTS DEC RN
undcrs
I red my plemsshell he used as pubic mcods
)yu
e� Licensed Professional
OWNER BUILDER DECLARATION
f I hereby reaso affirm the 1 tom exempt from the Contractor's Co License Law for the
5 p O whichlowng reason.(SeNon]s13str Business and w,derhns Code:Any city s county
m(v which myuims a pcmtil ret cnnnmcL a@q impmm,dcmnlish,or repair any nncmm
prior In its auuence,also requires the applicant for such permit to file a signed.nalemem
FO that he islicenscdpunuamrothcpmviaiomofNeConsrumrsLiauclaw(Chaper9 Sq.Ft. Floor Area VaIU
(commencing with Section 7")of Division 3 of the Business and Professions Cade)or
Nat he is exempt therefrom and the buss for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not mon than five hundred dollars S500L Occupancy Type
Q1,as owner of the property,or my cmployca with wages its their sole compensation,
will do the work,and the sweam is not intended ororfend for sale(Sec.7014,Business
and Professions Code:TOO Comncmrs Liana Law,dors not apply to as owner,of i' Required Inspections
progeny who build,or improms thercon,ind who dreamer work himself or through his
own employees,provided BOB such improvemem s am not amended or offered for sale.It. l !^
however,Ne building or improvement is sold within ons you of completion,the owner. 7
builder will have the burden of proving that he did not build or ampmm for purpose of % `1
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Convmtork Li-
cense law docs not apply to an owner of property who Wilds or improms thereon,and, J
who convects for such Projects with a contractor(s)licensed pursuant to the Convactoes ,
License Law.
❑ Iatn exempt under Sec. ,B&PC for Nis moan ` 1
« Dan
WORKERS COMPENSATION DECLARATION
_ 1 hereby&(firm under penalty of perjury one of the following decimations:
❑T have and will maintain a Cnnircan of COnsCOL to sel6asum far Workers Ch arem.
ution,as provided for by Section 3700 of the Latter Code.for the Performance of the
work for which this permit is issued.
❑1 ham and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for On,performance of the work for which this permit is issued.
MyWorker's ccurpewlp_on lnsunna carrier Pis ey number am:
CYTef: SPRY-� a Ja:J`�9 7�t
CEMFICATEOFFXEM ONFROM WORKERS'
COMPENSATION INSURANCE
Vo/l,section need not he completsd if the permit is froom:hundred dollars SUB)
or leu.)
I cenify that in the performance of the work for which this Permit is issued.I shall not
employ any person in any manners as in Itecome subject to the Woken'Compensation
Lew,of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cerdreate of Exemption,you should
become subject to the Worker's Compensation provisions of 1W Labor Code,you must
7p foMwath comply With such provisions or this permit be deemed invoked.
Z h CONSTRUCTION LENDING AGENCY
1 hereby airman that there is construction lending agency for the perfmmaao of
LaY the walk fur which this pemtit I$issued(Sec.7097,Civ.C.)
gl Q Lenders Name
jZ Lender's Address
;J Q 1 cenify that 1 ham mad this application and saw that the eWve information is
y H
correct.I agree m comply with all city and county ordinances and sale laws relating to
U building construction,and hereby aullonse mpmsentsfives of this city to color upon the
ahovo-memioned preperty for inspection purposes.
(We)agree to um,indemnify and kap hasmloss the City of Cupertino against
vi IlabRitle,judgments,costs and expenses which may in any way accrue against sold Cily
JZ in consequence of the good ag of this Permit. /o
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER GULATI02.
Ji 3 Re-roofs
I Lure of APPIIR=Ior Data
OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building scup ret at..or handle h.a oats mawnat
u defined by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safety
nc.5cction 23572(x)?
❑YeaNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building aau,4at use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit mandous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
El yes �Wu
1 have reed!me IanNnus hum nits requirements under Chapwr 6.95 of the Califon
nix Health&Stormy Code,Seethed 25505,25573 and 25574.1 undemmad that if the Wilding
doss not currently new s norm,than it is my resp«mibil icy a nod I the O cupant of the
mghimmcnawhich mum Wmet Pnortoissuance onCertificate of0:u ry. Signa[ureofApplicant Date
Sav� Ae sr 03
Ownc authorirntl ogcnl Date All roof coverings to be Class "B" or better