05040081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR,INFORMATION �r;
.xaaz'I�ffiR uIO `1,
BUILDING ADDRESS: PERMIT NOO 5040081
10495 DE ANZA ED
M'S NAME: PERMIT ISSUE DATE
BETTER HOME AND LOAN
ONI,,: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED I amCONTRACTORSunder
DECLARATION . Job Description
u❑ I thereby affirm Nal I am licensed under provisions of Chapter 9(commencing P
ZW withll(a=adeecDivision Softhc Businosand Prufcssions Code.mdmyliccnse is
n�a inmum a rade@[ TI--13 OFFICES/TOILET/T-BAR
i License Class Lic.g
arc Dam Contractor CEILING/LITING/CARPET/MILLWORK/PAINTING
F ARCHr1EC1"S DECLARATION
1 understand my plans shall he used as public records
JyU
3 u Elected Professional
a OWNER-BUILDER DECLARATION
0 1 hereby.(firm that 1 1. exempt from the amnion Cod :Any c taw for the
p O following reason.permit
t Tsyd str Business and w.de io i Code:Any city or county
i$� which requires a Permit m ennslmct,elle!,improve.dcmaluh,or mPair any urtmmre
F26 prior In
��$ i66Nanc0.alwrel lhroTar WchflRmil1 License
ifl[niaiganwed((Chapter
Sq. Ft. Floor Area
V+Id9@960Nhilicensed nttotW ovisiousof the Contractor
(commencing with Section 7000)of Division J nine Business and Professions Code)or
.. that he u exempt therefrom and On basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy
not mom Nan five hundred dollars($501 3 5917023 . 00
p y Type
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the someone u not immndcd or optimal for ame(Sea 70M,guineas
and Professions Cade:The Comramoses License taw does not apply in an owner of Required Inspections
property who Wilds orimpaases thereon,and who doessuch work himself or through his
own employees,provided Nal such improvements are not intended orolfemd for sale.If.
however,Ne building or improvement is said within one you of completion.Ne owner- ^
builder will base the burden of proving that Im did not build or improve fm purpose of 41
sale.).
0 1.as owner of the property,am exclusively connecting with licensed contractors to
convect Or project(Sec.70,14.Business and Professions Code:)The Conlnaor's Li. q+
cents law does not apply to an owner of property who Wilds or improves demon,and v
who contracts for such pose.with it contractor(.)licensed pursuant to the Connors
License law. J q
❑ I em exempt under Sec. .B&P C for this..be
er Date J
WORKERS COMPENSATION DECLARATION
Ihereby affirm under Penally of perjury atm of thc fallowing declarations:
101C,Iyl�,
htm and will mainuinaCenificam of Cansenuo sel6imum for Workers Compeer-
n,as provided for by Section J]Oo of Nm labor Code.for Nm perfarmanm of the
for which this pcnnit is issued.
have and will maintain Worker's Compensation Insumna.as royuimtl by$cctinn
of Nc lobar Cadet,for Ne performance of the work far which Nis Permit is issued.
orker's Camperuation Insurance exmicr and Policy number the
er: Policy Nis: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seNnn ted not W complcmd irlhe Permit Is random hundred dollars($100)
err less.)
1 certify that in the Performance of the work for which this Permit u issued.I shall not
cm play an,room in any ter u Wcomesublectro0tcwmkericonim anon
taws of California
Applicml
NOTICE TO e,/ ANT:IL e(mr maki isCertificatevissor or Exemption.athroccl You should
become subjcn t the Workers Compo ion provit mai of Nc toed Code,you most
.Jz foMwiNmm ywiN such pmvuidm or this Permit shallWOamed revoked.
ZO CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that Vert is a construction lending agency for the Performanceof
W> the work for which Nu .it is issued(Sec.3097,Civ.C.)
IvQ Landcfs Name
0 Lender'.Add.
U 0 1 certify that I have mad this application and sem that the above information is
U.F correct.1 agree to comply with all city and county on inances and sum laws totaling in
0U building construction and hemby audmim mpommstisea or this city to enter upon Ne
Y'ul aluove-mentiuned property,for inspection purposes
gy (We)agree 10 seve,indemnify and keep hannlm the City of Cupertino against
fag liabilities judgments.costs and expenses which may in any way accrue against said City
U z in consecration of dm granting of this permil.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL NON-PIssued by:9 Date
SOURCE R LATI
/rUg ° Re-roofs
Sign a of AppImanUCon Dam
HAZARD USMATERIALS DISCLO URE Type of Roof
Will On applieanl or future building occupant store or handle haaardous material
addefind by the Cupertino Municipal Code.Chapter 9.12.and On Health and Safety
.
Section 25532(a)?
0Yen `/ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hasardous air conumina u u cfined by the Bay Area Air Quality Management all new materials for inspection.
District?0Yet u
1 have mail the havardous materials requirements umerchap it(.950f the Califon.
one Health&Safety Code,Scn..25505.M577 anti 35534.1 undcrsmnd lhatirdc Wilding
dors not amt ly hast s tenant.Nal it u my mxporuibilil Duty a<u t err therequire wn� IWmelpn issaanaa ,afire yf dam- Signature of Applicant Date
or aathariscd sent Daum All roof coverings to be Class"B" or better