04040191 CITY OF CUPERTINO ' ' .a� a s a
BUILDING DIVISION PERMITCONTRA 34b TNI?ORMATION .
AR 3vrahL�'Fta.. '"�a...Y sig„-ass.. , '
BUILDINGADDRESS: & N CONSTRUCTION 'FR""6W040191
1
OWNER'S NAME: PERMIT ISSUE DATE
2004
HONE: SANITARY NO. CONTROL NO.
41B17 2-2168
ARCHITECDENGINEER: BUILDING PERMIT IN
B�� ELECT PLUMB MEC"
0o LICENSED CONTRACTOR'S DECLARATION`wJob DCSCrIpl100 ��F I herchy of onx that I am licensed under provisions of Chapter 9(commencing
with Section]000)of Division 3 or Ne Busoca and Psofcssiuna Code:and my license is
in full forte and effect.
LicemacCla, Lk;.a EMO--REMOVE INTERIOR .NON BEARING WALLS
Data COnOamar
ARCHITECTS DECLARATION
>? < 1 underuand my plans shall ho used As public mcorx
D v.0
;� Licensed Pmfcssional
OWNER-BUILDER DECLARATION
+�0 0 I botchy.(Sinn titre I am ucmpt from the Canons Co License Lew for the -
i O O following moon.(Stolon]Ions; r.alter.and improve,
d signs h.or Any tiny or manly -
u�$� which requires a permit m consumer.alter.imprnw,Jcmnit h.or repair any aWerurc
Z� nano its issue ,alsu _$1500
. p rcyuires the applicant for suchPermit
- Valuation
�o Ihmhelslicenxii Pu=tion7 lM1)Pmvisiom of the Contractor's License law(Chapmr9 Sq.Ft.Floor Area
a $ (cnmmcncing wish Sedian]000)of Division?of Inc 0usincu antl Pmfcuinns Ctbc)m
That he Is exempt therefrom and the bola for the alleged exemption.Any violation of
Section 7031.5 by Any Applicator for a permit subjects the Applicant o a civil penalty or
no359gPH PLSmBdd Occupancy Type
t mom Nen five hundred dollars(S30o).
❑I,otowwork.and
Pestooc,or is employcu withwages rtheir Solec .Business
will do dm work,ands:The C m is nota intended maRerctl for ak(Sec.IDN,Burow
and anywhProulaxiou tax:The Conuaerar, ndwho Iaav dao ar apply lf.n owrer is Required Inspections
propertywho build,orimpmvuchexprove woo Are„uch wmkhroffeorNmugh his
Own employees.prcg,or imatxchimprowmentsinmoc ynmMW m learcd for Owner.hosev _
bullde ill have
uimpmwrovingxtheld didnot year of completion.Ne owner. "J
builder will have Ne burden of proving than he did not build at improve for purpose of /s
I.a owher of the property.am exclusively contol with Iicenud contractors to
consumer Ne pmjeer(Sec.7044,Business and Profusions Code:)The Contractor's Li- t
cense Law does not apply to an owner of properly who Wilds or Improves thereon,and J
who contacts for such projects with a contractor(s)lie sed punuanuo the,Canu,cme.
License Law.
❑ exempt on C. B k P C for Ni,¢tion
0
—WKU'S COMPENSATION D ON ._
I hereby AM.unser penally of perjury ore of the following declarations:
I haw and will maintain a Ccouresm of Conscm to xlr-roam for Wo,lComp.a-
ulion,as provided for by Section 3700 of the labor Code.for the Performance of Lite
wait for which Nice permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the Labor Code.for the performance of Ne work for which this permit i,issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
am.)(Mix section need not M camplemd If the permit la for one hundred dollen(S IoM)
err
1 certify that in be petfmmanae of the work for which this Permit is issued,I shall not
employ any person in any manner so As in become subject to the Worker(Compewtion
Laws of California.Date
Applicant
NOTICE TO APPLICANr:If,shot making this Certificate of Exemption,you should
become subject on the Worker.Caonlrou ion provilima of the labor Code,you on.
.J O forthwith comply with such provisiom or Nis Permit shall be dmmcd rcwkod.
.za y CONSTRUCTION LENDING AGENCY
F I hereby affnm but Nem is a construction lending agney for the perfurmauc of
LYi the work for which Nis permit is issued(Sea 7097,Civ.C.)
CL,
Q Underi Namc
D z Lender's Addreas
U Q 1 certify that I have read this application and woe that the above information i.
I2. Pcancel I agree to comply with all city and county ordinances and auk laws rotating to
p U building consumerion,and hereby authonm representatives of this city to cnmr upon be �!
Cpl shove-mcntinnetlpmpcst for carame on purport
(we)agree m aw,indemnify and koep harmlm the City of Cupertino against
6.t z in Coiacque ce,ofh,eomand oapmuuwhich mryin any way accrue against City
U z inconsequence of Ne Bnnling of This pertnil. '
" APP RSfA S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
�ITIRCE REGU A
Re-roofs
411genure o PP Ica HAZARDOUS MATERIALS DISCLO E Dem Type of Roof
Will the applicant or future building Occupant Stere or handle haalloua material
As defined by the Cupertino Mun' tpal,Code.Chapter 9.12,and the Health and Safety
Code.Section 25572(a)9 All roofs shall be inspected prior to any roofing material being installed.
❑Yea Nu
Will the applicant at future Wildingoccuponl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit he'ardous air conleminanr JCGned by the Day Arca Air Quality Management all new materials for inspection.
lasrict'f ,gJ/
❑Ya Nu
I have read the havaeNm,m,mriaisruyuimmone unser Chapmrri.95 orthc Califor-
niaFlcaWhSafm Cax.S .25505,23533am12553a.lunkr ftiflM Wilding
d current Y a mnanL that it u my responsibility m entity then,omuput of Ota
rc tswhich ma etpnarmiaa mancetifia atom ry. Signature of Applicant Dale
Owner Or
onvcd Agent pare All roof coverings to be Class °B°Or better