03120066 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
RONT"'RAM] - y7ft
BGILDING ADDRESS: PERMIT NO,
SAMUEL CONSTRUCTION 03120066
OWNE44c; CTTPPPTTNO RD
WS NAME: PERMIT ISS(IB DATE
E:SUNNYVIEW I-TITHAREN HOME — -14-.)-7 17T.02AI-TIRT.A.- PAIR - SANITARY / //2 QA*OL NO.
RCHI3ECTIENG1NEE11i (_4nA� 24q_2P?A BUILDING PERMIT INPO MECH
BLDG EIPCI' PLUMB
LICENSED CONTRACTORS DECLARATION
I hereby afflon tout I am liesmand under prorrisions of Chapter 9(Demoncoeus Job Description
who Section 7M)ol[Dlvismn 3 ofthe Business and Professions,Code.mad my license is
in full]tz�i De/o=and air
Uc.0 REVISION--IN HOUSE USE ONLY
c a o ARCHITECTS DECLARA71ON NO NEW PERMIT ISSUED/ORIG. 403070059
I undermand my runs shall he used As public records
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby IMM that I am exempt from the Con wor's License Low for the
Ic a O rolinxing mourn.(Section 7031.5,Business and Professions Code:Any city or county
which Momincl A Permit to construct.almr,improve.demolish,or repair any someone
prion to its Issuance.&Lee requires the applicant for such Ferrol,in file a signed sudement
that he Is licensed pursuant 1.thethe Connector's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)=of the Butiness and Profiessmou Cole)or
Nat he I.Insompt demsefrow and the basis far the alleged exemption.My violation of —
Seaton 7031.5 by Any applicant for apermit subject,toe Applicant IDA civil Penalty Of APN Number Occupancy 14
not a.that One bmalred dollm,(M).
3 2 615130 . 00 Required Inspections
will do the work.and timthe muctione is notimbanded!Or011aredi lacted.(Sao.71144.Busimen
And Professions Codlk,'The COMMADVIR I JCCMAA taw does an["Ply W a Owner of
Property who builds or truparmucs duccon.and who times such wark,himself Or through his
own employees,provided thus such ho prowmearts sm not Intended a offamil taut,.If.
however,the Wilding or Impon"Anat is sold within am year Of completion,ft owmar.
Wilder will lume the burden of proving OW he did not Wild or impneme far Pumm Of
"m
.).
0 1,w oures,of ft propeany.Am exclusively"annealing with licensed cenuenon W
commenti to project(Sec.7044.Business and Professions Code:)ThO COMMAccel Li-
Damon:Law does not Apply In an manor of property who,builds or improves themor.And,
who contrach,for such projects with.centractol(j)licensed Famous anon Contractor,
License law.
(3I am exempt Order Sao a&P C far this
Owner Data—
WORKERS COMPENSATION DECUBATION
"com"ane
under penalty or perjury ume,of ft following cialamoosee
I lunemd will maintain a Cardlicam of Consent to self-insure fOrWODDesCmAPcA-
Mdon.As provided for by Section 3700 or the Labor Code.for ft Performance of the r
work for which this permit Is imaxi.
❑1 hanoc and will maintain Workers CDMPnSlllcn Insumacc,u required by Section
3700 of the Labor Com,for tho performance of the warl,for which this permit is iuucd.
My Workers C�mr`= MI""dPoii,nu
m r 1:
CmierPolicy No.:/
CATE OFMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section Dead net becompleaDd Irthe permit is foroachundecd deflars(SIM)
or 1.)
I comfy that in the performance of do work far which this permit Is heated.I slad not
employ any parsom In my marmer 0 As AD,become wb*l to the WOftm'CMPCMOGn
LA.of California.Game
Applicant
NOTICE TO APPLICANT.If.after making this Ceftillcatc of EUMPIuM.YOU Amid
become,subject W the Worker's Compensation provisions of the LAW Code,you a=
z forthwidi comply with such provisions Do this Permit"I DO doomedhomlool.
z 0
CONSTRUCTION LENDING AGENCY
14 1 home,"not tax,ftm is•construction landiol.goncy for the,Fort...of
> the work far which this Permit is is ad(Sec.3097.Cil.C.)
Lemic'.Name
Pz Lenders Address
U2 1 madly that I KIM read this Application and sum that the show infOormon I-
IL F building construction.and thereby autlecrim mprescrosti of this city An enter Drum ft
COOMCL I I=to comply with An city and crony onfirmacs,and saw taw relating M
alume,mentimon!P.Pcfly for Impaction purposes
(We) ,me to som,lochoraffy And hasp harmleas the City Of Caperton Against
liabilities,judgirculs,Com,And oxIameas which may in my way ccom againat Mid City
U in consequence of the imanning of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date )2-
SOURCE REGULATIONS.
I Re-roofs
Signature ofArIplicamVCommuser CC— Data
HAZARDOUS MATERrAtSVKtOSURE Type of Roof
Will the applicant or future Wilding Ducculnummarm orbAndic hazardous Material
As deffmcd by the Cupertino Municipal Code,Chapter 9.12,and the Health Md Safety
Code,
Section 255320)7 A All roofs shall be inspected prior to any roofing material being installed.
ED You No
Will the applicant or future building Occupant use equipment Or devices which ch If a roof is installed without first obtaining an inspection,I agree to remove
It Inemmus air crumuninums As dclmnal by the Bay Area Air Quality Management all new materials for inspection.
D
Oyu RD
I have mad the hexurdroomebacrolsouiummenes weer ClumM6.95 offt Califon.
niaHeitto&SafelyCode,Sccum 25505.25533 ml 1 understand dulifthe Wilding
does set cunently haw A Mount.this It is my malmosibility be omly ft necoPoral Of the
nurtircrocans which..a be Met Prior W ismarace of a Ccrdfic;m 0)0/�� Signature Of Applicant Date
Qben a "j
5- mZ All roof coverings to be Class"B"or better
Owner DaW