08060114 CITY OF CUPERTINO er„77 mai-
BUILDING DIVISION PERMIT' ,CaNTRACTQR I,NFaRMA'TIO1V
BUILDI G DRESS: PERMR NO.
7��!� DE FOE DR TBD — TO BE DETERMINED 08060114
'R'S NAME: PERMIT ISSUE DATE
POM PETERSON 07/30/2008
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoa LICENSED CONRACTOWS DECLARATION IOb Description
m 1 hereby affirm Out 1 am licenced under provisions of Chapter 9(commIencing P
_i withSection7")ofDivides3ofireBasin.andPofeuiamCode.WmyIi,--is ADD GA'LEBO(140SQFT) , REDO(E) BACKYARD.REPLACE
<„ in fall force and cnen
jyaZ Lice.Class Lle.g DECKING,REMODEL OUTSIDE KITCHEN W/FIREPLACE.
n i-GG Dam
Contractor
'Y ARCHITECTS DECLARATION
776 1 undersand my places shall be used u Public rtroNs
g a.
G Licensed Professional
OWNER-BUILDER DECLARATION
iE I hereby alum Nn I am exempt from the Conumtors License Law for ted
COO following reason.(Section 70I3,Business and Prefessiom Cole:Any city or county
which recut=a permit m construct,she.impur e,Mmov i h,or mIW,any metum
priarm ilsissuance.almrequires to ipplicam forruch permitth Ele asignoi swemcot
<
Mat Iisramedpursuant oMeprovismoaafMeContractor's ecnecLaw(CWpmr9 Sq.Ft. Floor Area Valuation
� (co00)
(commencing with Section 70of Division 3 of the Business and Pmfessiom Cocilor $30000
f5? Nat W is exempt Ocrefrom and the basis for Me alleged exemption.Any violation of
Scmion 7031.5 by any applicant for a permit subpcu me applicant W a civil penalty of
Man,five A,tk7�t Number Occas
nm roue Mve haredied doOsrs(Sm. 35925033 .'Vly' Occupancy Type
❑Las ewerof the pmprrty.or It employees wildages rde'vmle eW.Buiness
will do the want and Me suuaum u tet intended ma.do lm mala(Sec.to sm Business
and PmleWmu Code:Tia CesclumtoYs Lt.VW does tet apply lf,t owner is Required Inspections
own rnywho Wilds provided impalesrumor,mdwbo daessuinwort himselfalMmugh hu
owneer.me buildingmthatsuch entissld witmberml hin
not intendedaraaered for calm If.
builder.Mc building Meerhnpmwmantumide didnet year of mproleforn.theose r.
of
builder w10 have the WNm of proving Nat W did not Wim or improve for purpose o!
ask.).
B'1,u owner of the property m exclusively contracting with licensed contractors W
cmrlmet Me Project(SCC.]Bial.BaminCas read Professions Code:)The GamYYmes u. .
cave Law does not apply to m owner of property who Wilds or improves Merton,and
who contractsfar such projects with a conuactos(s)lieuued Famous,us Me CanuxTo(s
License law.
1 am exempt uodw S�eI ,B&P far To
D.7 o sC[
WORKERS COMPENSATION DECL,kRATION
41 1 hereby affirm under penalty of Pnjmy arc of On following declaradossc
1 have and will maintain a CWBwte of Content to self-alum fm Workers Compen-
sation,as provided for by Scedon 3700 of Me Labor Code.fm the performance of the
wort for which this permit is issued.
❑1 have and will maintain wertces Compensation huurnta,as required by Section
311)()m Me Labor Code,for Me performance of Me work for which Met .it is issued
My Workm's Compensuian Imran¢onus and Policy number ase:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(TTissectim need not IN completed if the Permit is forams hundred dollen(SIOm
or ins)
I certify Mat in the performance of Me work for which this permit is issued,)shall not
employmy permit in mym eer m Wcome subject m We W Or Pe am
Un of Califomis.Dame V
Appl ant
NOTICE TO APPLICANT:If,-afer making this Certificate of Exemption,you should
become subject m Me Worter'i Compensation provisions of the fabm Codc,you most
.J z fonhwiO complY with such poririnm or Mu Permit snail IN deemed revoked.
?O CONSTRUCTION LENDING AGENCY
[—t I thereby affirm Mat Mcm is a comtrucion lending agency for the pemormanco of
a > Me.,it for which this permit h issued(See.3077.Civ.C)
A Landers Name
,Z) z Lenders Address
U 0 1 certify Mat I have mad Mia application and auto Most Me aWw infommen u
IL F' eoat ts1 agrawn
ee W comply with all city and county oadinans and ewe laws relating th
DU Wilding convection,and hereby mthorm rtprtunutives of Mu city to enter upon Me
LU aW.-mentioned property for inspection purposes
g1a (Wc)agree to saw,indemnify and keep harmless tie City of Cupertino against
Tq liabilities.judgments,casts and experses which may in my my aerie agalmtuid City
U inC-seemace.of the training of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:%O� aDate 7
SOURCER U Ns. I / Re-roofs
1u�(
.1�1// o
Stgnuurt ofd ha410muactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me 1Pliesn1 or future Wilding oreapmt stem m handle hmamom material
dcBnN by Me Cupenin r Municipal Cade.Chapter 9.11.and ted Health and Wely
. CY.25532(.)7 ^,/ All roofs shall be inspected prior to any roofing material being installed.
❑rte te✓'
Will Mea licantorfuture Wilding oeru acetum e m If a roof is installed without first obtainingan inspection,I agree to remove
cep g e V nr Qm or Mara when P
Ci�W?udnm air contaminmu u fir¢,by Nc Bay Arra Air Quality Mmgemcol all new materials for inspection.
❑Yu Nu
I haw resv Me nvamws mammals requimmenu um er Chapter 6.95 of the Califor-
maHealth&Safety Cod,Sxdwu 15505,15533 sur 25534.1 masesund Me if Me Wilding
does not currently have•ens bol it is my responsibility in or,Me eupan or Me
requirementsw armissuanceoftCcauftcaeof Signature of Applicant Date
Ownerormthomcdagcru Dam All roof coverings to be Class')Iy'or better
l