06020154 CITY OF CUPERTINO MI
BUILDING DIVISION PERTGOV'..".['RA,CTOIt
BUILDING ADDRESS: PERMIT NO.
06020154
oA PERMIT Issue DATE
Na: SANITARY NO LNG.
ARCHITECTIENGINEER: BUILDING PERMIT INf-0
'BLDO ELECT PLUMB MECN
o I� o
f LICENSED CONTRACTOR'S DECLARATION lob Description
y 1 honesty afRn Nn I me limesod under provisions of Chapmr 9(commencing P
d with Section TOM)of DIAslon 3aftho Business and Professiam Code.and my lteeme,is
in full farce and cram.
License Class Lte.0 ADD 940 ' 1ST FLR FOYER/STUDY-2ND FLR MSTRBED/BA
Dam Omitromar
ARCHITECTS 0"
RECONFIGURE/REMODEL 1240 ' REST OF 1ST FLR
I uMcnunJ my Priam shall W used u public menthe
Qo
Liocmed Pmfentianal
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Conuattor's License Law rat the
O (allowing mmon.(Section 7031.5,Business and Profession Code:Any city or county
S which Iequlrn a permit to contacts,after,hnprom.demolWr,Or repair my stmetum
e r prior in its tssuame,alw requires she appliemt for such permit to ale a signed statement Valuation
< that he Is licensed purswm to the provision of the Contractors Lim^m law(Chapter 9 Sq,Ft. Floor Area $326438
-S (commencing with SwoonTwo)n(Divnlon7aftW Busimu and Profession Cnde)ar
9. that he is exempt therefrom and the basis fon the alleged re reptiom Any violation of
Section 7031.5 by any applium fon a permit wbjecm the applicml m•cfvll penalty of APN Number Occupancy Type
not mom thm A.hundred do1W(g500).
O 1.m owes of the property.or my employes with wages is their w1.compermW^n.
win do thewwk.and we almesumla nwmmnded oraflued Russia(Sec.704+.Business Required Inspections
ad Profession Cade The CaallCmYLaw does License Ladoes sat apply m er m owaof q P
Property who builds orimprm s thernn.and who do esuch werkhimmlfor Woogh his
own employes,provided wt Inch irepaamentaamnot I.-, or offered for Sell If.
however.the building or impoO mtmt is sold within cm year of completion.the owner.
builder WO have the burden,of proving that W did at build w improve for purpose of
Mm.)
❑1,as swam of the property,sm eulutinly commning with licensed entrSuma or
construct the project(Sec.7044,Business ad Prowsiona code:)The Countesses U-
c nae Law dont as apply no an owner of property who Wilda or improves shaman.ad,
who comncu for such pmjeers wish a conaeror(s)licensed pursuant or the Contractor's
License Law.
❑1 an exempt under Sm. B a P C for sh4 muov
"
Owerr"'Z:�W�%� L e.��_Data 'S d
ORKERS COMPENSATION DECLARATION
1 hereby grim under penalty of perjury One of Ih following decimations:
I have and will maintain a CertTacom of Content to self-imum fm Workses Compen.
colon,Is provided fon by Section 3700 of the labor code.forum perfonmx,of don
work far which this permit Is issued.
❑1 hue and will maintain Workees Compensation Instumm,as required by Sat in
3700 of she labor Code,for the performance:of the work for which this permit is named
My Workers Compensation lnsulanm carrier ad Policy number mm: --
Carrier: Policy N^.:
CERTIFICATE OF EXEMPTION FROM W ORKFRS'
COMPENSATION INSURANCE
(ThisseNn mad oat W comp1.md U the permit is foram hundred 09.(SIM)
m Ina)
I ocnify Not In the perfomance of dm work fon which this Immnit" issued,14rsil es
employ an5'peronln apy.m beesma ryGJ<mm a 'CompwNn
Lava of Calirmo• rf_--fes
Applicant
NancF TO APPLICANT.If.after making this Ccrdrrnm or Exemption,you should
become subject m Ne Worker's Compensation provisions of the Labor Cade you most
Oforthwith comply with Such provolone Or this permit Shall W deemed remixed.
CONSTRUCTION LENDING AGENCY
fi•y IMmhy affirm that thea is a construction lending agency for the performance of
ti dm work for which this penit is Issued(Sec.3M7,Civ.C.)
Q Lender's Name
r
Lender's Address
0 l certify e c 1 lave mad this city
aid coon and sum that the above ons mladun 10
t!`
building
I agree m comply with sit city and county ordinances of
is auk laws r upon t e
t rU' 4bon-gcmionedro wdhereby Ins wNoda `m of oris city menmrupnn the
r f17 suint-mendon re to ertysam for Inspectionkeeplpurposes
r c i (WC)agmer m rove,ad expert and hcep hay in m the City of CmpaNno ideiw
VI inComejudgmen0.cormandof thises which rosy in my nyemroe.gsiw said Lily
Iz mPLICANm of the gralingUNDERSTANDS
of thispermit.WILL
^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
s0 T ONS.
S Re-roofs
Signmua of ApficionlContriSbirD
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Its applicant as future Wilding gaup e'somm or hadle hau mus armanst
a defend by the Cupertino
Municipal Code.Chapter 9.12.and dm Health and Safety
coda,Section 25532007 / All roofs shall be inspected prior to any roofing material being installed.
❑ye, ei
Will the applicmt w future building occupant use equipmcnl or devim which If a roof is installed without first obtaining an inspection,I agree to remove
it hae roma air conuminanu as dclined M the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 014
1 hammed the hmmem m^mdalsmquimmenu underChapmr6.95^ftheCadfw.
nia Hcolth&SmfelyCode.S=am25305,25533wW25534.Imelcrandthatlrte Wilding
does not cwmmly ban a mmol.Net It u m 7mponibllily m nodry the aceupmt of the
myulmmenu which mush be met i mceor a CeniOesmofocc incy. Signature of Applicant Date
crwwshammde cm Dam' I All roof coverings to be Class„B„or better