04040020 cITBUILLD G DIVISION NO PERMIT ICON RACTO*I�NF.ORMATI,
-.
BUILDING ADDRESS: PERMIT NO.
THOMAS SCHAEFER 04040020
NEWS NAME: PERMIT ISSUE DATE
12
UNE:T OMAS RCT SANITARY �ftOL N0,
ARCHIIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
up1 LICENSED CONTRACTORS DECLARATION Job Descriptio2��I � ,a ®
V I hereby affirm that 1 am liccucd under provisions of Chapter 9(Commencing awy�
ith Section 7")of Division 3 of the Butdom and prefessium Cock.and my licenm is
Z „ Ucanas lass rra ADD 80 SQ. FT. /UPGRADE AUG 2004
? License Clan Lie.« Q
w p-p 0 Dam ARCHITECTS DECLARATION /
I.ndentand my plans shall Wooed u puhliC racnNs
BUILDING
C.t, Licensed Professional
5 ran lam exempt
m Ce ComorON
.�n o I naso affirm that I 01 . exempt from dm Cessions res License law for ted
-00 which following reason.(Section construct,altar.
and w,de tom Code:Anyepairay OfCounty
$ which requires
a proton us enn a the alter.improve,demolish,ri reps.any udamere
FR< pdormiBcensed c,also nt1.the the for Ccnfachn's o rile Co.. Law(ed statamcnt
thathecingwiitpSecuanuon 7")ofDivisioofNeComrumrindProf io(sCode)9 Sq.F[. Floor Area Valuer[on
yrs (ntoMis turapt Seefrard ndrac Diasisfron 3 nfthe Business and...tenyvi Code)of
that he u exempt therefrom and ted buil for ted alleged exemption.Any violation of
Section 2031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 MNP-40*z-0 0 Occupancy Type
not more Nan five hundred out[..(SSW).
D 1.an owner of the pmpeny,m my employees with wages as their sole compensation, "
will do ted work and the someone is not intended oroffmad tarsale(See.2044,Business
and Prof.—Code:The Contractors Limente law docs not apply to an owner of Required Inspections
Property who Wilds.,improves thertoC.md who doessuehwmk himself.,through his
own employ=,provided that such improwmensl are notinumced or offered for sale,If,
howevco the building or improvement is sold within one yea of Completion,the Owns-
builder will have the burden of proving that he did not Wild or improve for purpose of
salt.).
D 1,as owner of the property,am exclusively contracting woof licensed contractors to
comuuct the project(Sec.2014.Business and Profnuum Cade:)The Coamnstnrs Li-
come law docs not apply to an owner of propcny who Wilds or impmxel Narcan,and
who contracts for such pmjecu with a eomraher(s)licensed punuam to the Conoutoes
License law
❑ 1 em exe t unda$ec. .B&P C for thi mason
er� </J a
W 'S COMPENSATION DECLAR��A N
I hereby a n under penalty of perjury ane of the(."Mowing deelaaffma:
I haw,and will maintain a Cenlricato of Consent o self-insure for WorkcrsCompen-
satinn,as provided for by Section 32W of the Cadre,Code,for the performance of the
work for which this permit is issued.
D 1 Isaac and will maintain Wortcr's Compensation luta.orm.u required by Section
32W of the Labor Code,for the panumurce of tha wort,for which this permit is issued.
My Workers Compensation Insurance Cartier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if tae Permit Is(.rote hundred dollars(SIM)
or kis)
I Cenify min the perlmmanee of the work for which this permit b issued,l shall nm
employ. person in any man�hpcoln��ubjecno oft W.rkers'Compensation
taws of C) afy({ -�
Apphc�
NQQr�Iff��E ,agar mak g this Certificate 0 Exemption,you should
b)(Kwi esu jmptothe hComsor Otis
nermit mal of the IaWr Code,you man
.JO for ofComply with such provisions or Nis permit shallWdccmc0 rewked.
'zy CONSTRUCTION LENDING AGENCY
j-+ IWtoby affirm that them is a convection lending agency for the performance of
fY> Out wurk for which Nu permit is issued Ise,3092,Ci,C.)
0.Q lenders Namc
,a Z Lendcri Address
(J O 1 certify Nat 1 haw read this application and state that the ahove information is
" F-' coned 1 agree t.comply with all city and county oud a mos and srme laws relating to
per building convection,and hereby authorise mpresematiws of Nis city to enter upon Use
r alx,e-mcntimacd prepeny for inspection purposes
(We)agree m saw,,indemnify and keep harmless the City of Cupcnino against
f' Caj1 liabiliues.judgmcno,costs and expenses whipernan.m may in my way acme against said City
in consequenc
llZI
U ^ APP IL CANTCUNDERSTANDf to WILL COMPLY WITH AL NON-POINT Issued by: Date
SOURCE REG AT16N
L Re-roofs
1.
signs PPI H o OUS MATERIALS DISCLOSURE Type of Roof
Will the applicator or future Wilding occupant store or handle havudous material
as defined by the Cupertino Municipal Code.Chaptar 9.12,and the Health and Safety
AC.Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Dyes ZI No
Will ted applicant or future Wilding Occupant use equipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil havasdnus air Contaminants u dcfncd by the Bay Area Air Quality Management all new materials for inspection.
Diann?
D Yes 151.
1 haw read the WaNtws materials rtl.ircroc us under Guitar 6.95 of the Calif..-
.is Health&safety Code.Secvau 25505 5533 and 25534.IumkrsuM that if ofe Wilding
doesyto t cu Ww ani Nu' my mxp.nibility to Corti Iy de occupant of the
mq.itt'me who muse ma miss.anettraeenifita¢nr09e` Signature of Applicant Date
Owne.ma.m.ti.<dase YY Dam All roof coverings to be Class "B" or better