05060033 r_mY OF CUPERTINO 4,
BUILDING DIVISION PEIUMT
LDING ADDRESS: TOM PETERSON PERMIT N005060033
76�04 DE FOE! DR
c cR' A PERMIT ISSUE DATE
ONE:TOM PETERSON SANITARY I r;/2 gab L NO.
0
ARCHITECTIENCINEER: BUILDING PERMIT INFO
BLDG MFCH
LICENSED CONTRACTORS DECLARATION ts PL!f
I hereby affirm that I ma licensed under provisions of Chapter 9(commencing Job Description
im Section 7000)of Division 3 of We Business and Proultsmons Cow.And my licers,Is
full force and ciTem. KITCHEN/BATH REMODE
Licentat Class_Lic.I
ARCHITECTS DECLARATION IF INALEU
DOW Contractor
I understand my plans shall Im used As public records
Licensed Professional OWNER-BUiLDER DECLARATION FED
I bumpy AMM that I am Attempt from dree Contractors License Low for the
�02 following mamn.(Section WA 1,5,Business And Professions Code:Any city or county
1 which requirts,a parent,to construct,altar.improve.dcamalish.or repair my Wasenum
14� poor an its issuance,Also requires the applicant farstach Permit to rile a signed statement 0 0 0 0
"he Is licensed parmant W ft PandSWAS Of the COfflnuctor's Locanc Law Chapterl) Sq.Ft.Fl�or Area LUE1111rull 'J'Q&Aluation
(conamencias with Section 70)B of Division 3 ofthe Businsusand PonfessimuCadc)at
dust he is exempt thourefrom and ft basis for the Alleged excreption.Any violation of
Section 7031.5 by Any applicant for.pasmal,Aub*U ft applicant to a civil penalty of 35093QMer00 Occupancy Type
set more than five hundred dollars($500).
V1,As owner or the property.or my employees witan wages As two=to compensation,
,I do the.,L ad We mucium is an[intended or offered por sale(Sec.7044,Bussmen
ad Pareadoes;Cc&:Tire Combat License Law does an[apply to an owner of Required Inspections
property who Wilds orimproves Wasomen.aradwhodoessuch work himselfor through his
Own employcest provided that such ITAPPOCAMMIS Am not intended OrGiresed future.If,
however.thx building a improvement issold within an ycor of completion.the comer.
moidar wili have the human or proving that he did am build or improve for purpose of
"[a I.
E]1,As Owner of the property.Are comiustwly contracting with licensed wattradws to
cmubwt the project(Sm.7W.Business ad Pariession,Code:)71W Comiscria's Lt.
came,Low does at apply tasm ow.of property Art.builds a,Import.ft..And,
whocontrad,par such projects with a conaresmar(s)licensed pursuant to the Contractor's
License Lt..
1 ma exempt a ft
B&P C f
.Do.&—/P_610
WORKERS COMPENSA71ON DECLAWArION
I thereby afflart under pasualty,ef Plajtay mandthe following countersue.
I hra.md will nommahn.cWtilicatecofCcurazard in saif-imitax fierWmIser's Compam.
Milan.As provideat for by Section 3700 of ft Labor Code.for We parformarace of ft
t i
weak for which this permit Is issued.
1 haw And will maintain Warker's Compensation Inammunce,As required by Sedan
a
3700 critic Labor Code,for dw performance ofthe work for which this porml,is Issued.
My Warcoei Compensation Inswounce carrier And Policy number am:
Carrier.—policy Na.:
CERTIFICATE OF EXEMPT70N FROM WORKERS'
COMPENSATION INSURANCE
(pus section wed not be completed Ifthe passed,Is ficarom,hundred dollars($100)
a,Was.)
I certify ft,I.ft PmrrmmWw`of ft mit I pernit is Wood.I mail nor
mrpl.ymy person in any At bject�.theWorlano'Compensadon
LawsofCalifornis.. q
NOTICE TO APPLICANT.If.Mer making this Certificate of Exemption.you should
become subject,an the Worrian's Con,comation provisions of ft Labor Code,you mesa
z forthwith comply with such provisions or this Permit mail lot deemed ranked.
z 0
E n CONSTRUCTION LENDING AGENCY
I thereby*Man that them Is a construction lending agcmy forma Performance of
ft work for which this remit is issued Sec.3M.Civ,C.)
ZD z Leader's Address
U C) . Iccally that thaw mad ddhisplismion andstaut the,ft storat information Is
D, comm.I ajocc to comply with all city and county onfircurects and suare ism,miming to
0 building consumcdon,ad hereby sumorks,mpocasannotim or this city to enter upon ft
above-mcadoned property for inspection purpown.
Ill. (We)agree to saft.indemnify and laort bourades,ft City of Cupertino against
W liAbitida,judgments,coss,tend expenses which may in any way accrac against mid City
In consequaraw or the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REoM -or
C 1!�_6 Re-roofs
Signature ol'ApplicasoulComombor Dow
HAZARDOUS MATERIALS DISCLOSURE 1�pe of Roof
Will the applicant or future building occupant stom or handle haiamdous material
dell d b the Ca I Municipal Cow,Chapter 9.12,and ft Health and Safety
-W-0 =Z.25532(pien?00
Yes All roofs shall be inspected prior to any roofing material being installed,
)i!�o If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant usa,equipment or dcvicas which
'7 1 1 lawArdnall Air commatinarms u dolind!by We Bay Area Air Quality Management all new materials for inspection.
District?
El Yes X11.
I bem med the hassualmer.materials requiromenu;under Chapter 6.95 of ft C41ifor.
"is Health&SaicyCode,Sections 25505,25533 and 25534.1 maintained that Ifft building
does set cuommly have.conam.that it is my responsibilily to notify ft occuparx,of me
require k Poor"b"u"or-cc:e��jfP' Date
:��' me, Signature of Applicant
Owner or utlamixed agent All roof coverings to be Class"B"or better