04070180CITY OF CUPERTINO
DIVISION PERMIT
CONTRACT016INFQRMATION
BUILDING
BUILDING ADDRESS:
L AND D CONSTRUCTION
PERMIT NO 04070180
10555 DEOnARA DR
OWNER'S NAME:
PERMITWUR DATE
RICHARD ULMAN
1555 YOSEMITE AVE 41 7
/2nn4
yE:
SANITARY NO. CONTROL NO.
(415)822-8383
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Mreby affirm shat 1 am limed under provisions of Chapter 9 (commencing
wile Section 70M) of Division 3 of Use Business and Professions Code, and my license is
infull force and effect.
REVISION --TRUSS SUBMITTAL (DEFERRED)
License Class Lk.d
Dau Con,.,
ARCHITECT'S DECLARATION
1 understand my photo shall he used as public mentis
,
Licensed PnRcssianal
OWNER -BUILDER DECLARATION
I hereby afOrm that I am exempt form the Conuacto's License Law for the
following reason. (Section 703I.S, Business and Pmfeuium Code: Any city m county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior in its issuance, also requires the applicant for such Permit to file a signed statement
Sq. FL Floor Area
Valuation
that be, is licensed purauanuo one provisions of the, Connectors License Law (Chapter 9
(commencing with section 7") of Division 3 of the Business and Professions Cede) or
that he is exempt thcmfrom and the basis for the alleged exemption. Any violation of
3 @daRtBer OO
Occupancy Type
Section 703 L5 by say appliarn for a permit subjects o, applicanrto a civil penalty of
not marc toast hundred delta. (S5Mk
❑ 1, as owner of the property, or my employers with wages as their aolc compensation.
Required Inspections
will do the work and the structure is not intended or offered for sale (Sac. R)aa, Business
and Professions Code: The Coruacmes License Law does not apply to an owner of
property who builds or improves thereon, andwho dmssuch workhimself or through his
own employees, provided thauach impmsemmtsare not intended oreRerd forsale. If,
however. the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build at improve for purpose of
l
vie.).
awmr of ter property, amu uaivdy contracting wilt licensed conuecmrs m
*weof t(Sea?Oaa, Busi ass and Professions Code:) The ConButrrs Li
c nslmm
V
V
came, Lavdors not apply man own of property who builds or improves thereon. and,
whocontracuforsochprojecuwi acon=tor(s)limnxdpursuantmthe Cenm WeS
\ ��
License Law.
❑lam ex undo c. - B h PCIm
�Nfisresson
Own,t
U ORKER'S COMPENSATION DECLARATI
]here aRrmunderpenaltyofpexjmr,m.oft± fall ing declarations:
W aid will mountain a Certificate of Consent o self -insure for Workers Compete
on, ns provided for by Section 37DO of the Libor Code, for the Performance of the
weak for which this permit is named.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37W of the labor Cade, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance caner and Polity number are:
Carer,Policy No.:
'
CERTIFICATE OF E%EM MON FROM WORKERS'
. COMPENSATION INSURANCE
(This section need not Weompleted if the permit is foray, hundred dollen (SIM)
or less.)
I certify Nat in tic perfutmanee of du work for which this permit is issued, l shall not
cmple, any person in any manner m a to lissome subject o the WorkersCompensation
Laws of California Dau
Applicant
NOTICE TO APPLICANT: IL after making this Cenificate of Exemption, you shoiW
bcmme subject an the Worker's Compcnxdon provisions of the Isom Code, you muss
foMwith comply win such provisions or this permit shall the reamed revoked.
CONSTRUCTION LENDINCAGENCY
1 homey Wt there is construction lending agctxy for the perfuanenm of
cErte
i s
' the work for which nice permit is issued (Sec. 309'!, fie. CJ
lancer's Name
Landcri Address
iI mnify tat I have =it this application and sou net the shove informniun is
unea I agree m comply with all city and county ordinances and sou laws relating to
building conswctian, tate hereby euthemertprexnutivrs of Niuity mcnter upas one
abovcmentinned property for i cuon purposes.
(We) asrte to save, inJe nify and keep harmless the City of Cupertino against
han xpcnw which may in any way accrue against said City
j liabilities. judgments, Co.V7
in conxgmenec of the goad i f this persdit.
' APPLICANT UN RS NDS AND WILL COMPLY WITH ALL NO -PINT
Issued by: Date
SOURCE R
Re -roofs
signet of "re.nUContncmr u
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
I the applicant er future building occupant stem m handle ha�ous materiai
.1 d by rte CuNnine Municipal Code. Chapter 9AL and the Health and Safety
Code. Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
�Y No
If a roof is installed without first obtaining an inspection, I agree to remove
Will mea applicant or wore buildin coca ant use e t or devices whim
rap s p
. Air Quality
it hararrnus air conuminanu az dcfncU by the Be, Arca Air Quality Management
all new materials for inspection.
arts?
E] Yea
i
(haveredthehar nu aurialsmquimmenuunder Chapur6.95ofthc Califor.
d
nice Hcalnl SWcsyCodc,Smti 25505,25533and2553d.lundersunducatiflhe Wilding
/
Jmv not cmr,mly cam rat Nat it is my rtsponsihility m sadly the occupant of nc
mquicrcne hi met hertertmof]crouleateoro uparcy.
SignatureofApplicant Date
) f&C
All roof coverings to be Class "B" or better
'ted
wneror rut ascm Da
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