04010054 CITY OF CUPERTINO
BUILDING DIVISION PERMIT WQ-QNT- ,, R4INE0RMATI0N `*
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BUILDING ADDRESS: SAMUEL CONSTRUCTION PERMIT NO.04010054
OWNER'S NAME: PERMIT ISSUE DATE
SUNNYVTEW
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SANITARYNO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
nOp LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 hereby affirm that I am license der provisions Or Chapter 9(commencing P
with Seepp'on]0J�0)af Di "en 3 ofta Bins p .d Pmkisiom Code.and my]neem is
Un in full Inks5�de
5t2i Llees CG Lie.« Seo"/772 REMODEL (REMOVE BATH/ADD KITCHEN)
w /z T'S DECLARATION cons ROOM 474/76 & 441/43 5�
pp ARCHRECTS
;g ndersand y plans shall k usctlav nub11E records
Licensed o MAR 1 'l 2004
O OWNER-BUILDER DECLARATION
Y I hereby affirm Nn 1 am exempt food the Contractors Liecnt Law for the
_O O rallmvmg mama(Section 7031.5,Business add protestations Cock:Any City tar county
which recants a permit to ennsmser.alter,improve,demolim,Or repair any ona,me
FZi prior in its issuance.also requiem the applicant for such permit to file a signed statement
Nat he is licensed pursuant the puNiskia of the Contractor's License law(Chapter Sq.Ft. Floor Area
tt
to (commencing with Section]W%M Division 3 of the Business add Profeuiov Codd)at
Nat k u exempt thctfom and on buss for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mot Non five hundred dollars(S500).
C3I.uowmr of Ne pmpeay,or my employes with wage udair sok rompenutlon, 32615130 00
will&lhewareandtheswaum isnotmlendedoroBereelforsalusec.7(144,Business Required Inspections
and Pmfessiom Code:TimConvmmrs LiceoY law dam test apply o an ower of q P
property who builds ori snows thereon,and whodocssuch work himselfor through his
own employes,provided Nat such improvements sae not intermit mmcmd ferule.IL
however.the building or improvement is mid within one year of mmpledon,Ne owner.
builder will haw the Winters of moving that k did not Wild or improve for purpose of
sale.).
I,as Owner of the property,am exclusively contracting wit licensed commoLOM sem
consuuct the Fruits,(Sec.7W.Radium sand Pofr emors Code:)The Contractor's U.
rue law doer not apply in an owner of property who Wilds or improves themon,and
who contracts for such projects with a contractor(s))named pursuant to doe Conexactmes
License Law.
❑1 am exempt under Sec. :B A,P C for thu moon
Owner DataWORKER'S COMPENSATION DECLARATION
1 hemby affirm under reality of perjury one,of the following declaruions:
❑1 have and will maintain aCerdfiare of Covent o xelf-imum for Workeraeampen-
as ion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which Of,permit is iuueQ
1 have and will maintain Worker's Compensation Insurance,az mquired by Section
37W of Ile labor Code,for the performance of the work for which this Permit is issued. _
My Worker's Compensation Insurance carrier and Policy number scare�: �a
Carrier. meta T-%J Policy No.:60z6633J ZM
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONIN RANCE
(Thu seinen need not kcamplcte rmit is for one hundred dollars(S I Or
nr less.)
1 certify Oat In the performance of the work for which this permit u issued,I shall not
employ any person in any mannerso as to become subject to Ile WorkcrY Compensation
Laws of CA romia.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate Of Exemption,you should
become subject in Ne Worker's Compensation provisions of the labor Code,you muss
.J,Z forthwith comply with such pmvuiov or this permit shall he deemed mvokcd.
ZO CONSTRUCTION LENDING AGENCY
[— .N. (hereby affirm Nat them is a construction lending agency for the pci tmanCe of
a> the.,it fur which this permit is issued(Sec.3091.Civ.C.)
fA 0 Under's Name
Z Lenders Address
U I certify that 1 haw mad this application and some Na the above information is
gL f cancer.1 agree or Comply with all city and county amivnm and scale laws misting to
0U Wilding construction,and hereby authorise mpmsenativu of this city to enter upon Ne
r W akve-mentioned poperty for ivpuction purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
F•'y Iiabiiities,judgmcns,costs and examines,which may in any way acerae against mid City
U in consequence of the granting or this permit.
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ERREG LA] NS. _
Z b Re-roofs
gnaturc of lican actor
DOUS MATERIALS OSURE Date Type of Roof
Will the applicam or fmme building occupanistt or handle humorous material
az turned by Ile Cupenino Municipal Code.Chapter 9.17,and On Health and Safety
Code.Section 25532(a)7 All roofs shall be inspected nor to an roofing material beim
Ii ❑Ya ti(r)e P P Y g g installed.
\ Will the applicam or future building occupant sae equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haurdom air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
Diatrict)
❑Yes No
1 have mail the hvafdnuusCmawHab mquimmcnu uMm Chaplcr6.95 orbs Califor-
niaHcalthhSafety Cade.S m25305.25533=d25534.1unanmv airthc Wilding
docs not cunemly haw a anent Nat it u my maponsihility m notify Ile axupant of be
requirements which Must k mem t poor miumucc or a emBate of ac Bracy. Signature of Applicant Date
All roof coverings to be Class"B" or better
r ora mriacd tag Daa