05040066 CITY OF CUPERTINO 'x"';
BUILDING DIVISION PERMIT CONTRACTORhINFORMATION. .
_ '�S`bg�-^#e"'_3.o-i-iZ�d, sa,3^•oza-u 'LCkk
BUILDING ADDRESS: PERMIT NO.
BROOKE RAHN 05040066
OWNER'S NAME: PERMIT ISSUEDATE
E:
SANITARY OL NO,
ARCHF]ECUrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°00 LICENSED CONTRACTOR'S DECLARATION Job Description
s u C 1 hereby affirm flm I am focused under provisions of Chapter 9(commencing
<Z U. with Saumn 7")of Division Sof dm Business and Profcssiom Code,and my license is
^<n, in full arc and erican ri
5gzLieena<Class Lim.g SHEETROCK/INSULATION/ELECT . �WATER� HEATER
Date conuanar
ARCHITECT'S DECLARATION
(HALLWAY�MS BEDRM)
z i I understand my plans shall Inc used as public secmds _ /
;g LicensedProfeaaional 7 ! 7!J"�
`i to I OWNER-BUILDER DECLARATION
f 1 hereby Orion that I am exempt form the Contra Ides License Law for theT ,
i
00 following reason.(Section]1171.5,Business and Professions Code:Any city m county
u$ which rtyuires a pernit to co.,.alter.narrow.demolish,Or repair any uruaum r. t (�
rd�w prior m itsissuance.also requires the applicantfor such permit to file a signed statement ,i
i�< That he u licensed pursuant the pervishma of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area -- - \• uValua
x 000
w�S (eahe iscingwith 7")of and
Divisiofr the
alciodcssand Professions GWe)of
Nat he u exempt thererrom and Ibt baso for the Jlcgcd exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than fits hundred dollars(5500). '
❑1,u owner of Ne pmpeuy,m my empmycs with wage u their wlc comm=tion, 35928017 . 00
will do thework,and the swcmm is notinmtded proffered forsalo(Sec.7W,Business Required Inspections
and Professions Code:The Comment's License Law does at apply w an owner of 9 P
property who builds or improve thereon,and who docs such weak himself or through his
own employee.provided that such improvements are not intended or offered for sale.If,
however.the building at improvement is told within ane year of compound.the ow--I-
builder will bars tax burden of proving dust he did rot build or improve for purpose of
axle.).
O 1,as owner of the propcny am mclusiwely contracting with licensed eonuutms On
Construct due project(Sec.7000,Business and Professions Code)The Canvasser's Li.
rax Law dors not apply to an owner of property who builds or barrows teencon,rod
who contracts for such projects with a conuacmr(s)licensed pursuant in the Conmacsofs
License Law.
❑1 am exempt under Sec. .B k P C for dais recon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I haw and will maintain a Cenifcske of Cort nt to mlf-insure fm Wmh(sCompcn-
sation,as provided for by Section 3700 of do,Labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Latour Code.for the performance of the work for which this permit is issued.
My Worke's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not N completed if tar Permit is farone hundred dollars(5100)
or less.)
I certify Litt in to performance of due work for which this Permit is issued,l shall not
employ any person in any manner so u to Wcome subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this CeniOcam of Exemption,you should
become subject in to Worker's Compensation provisions of the Labor Code.you most
.J O forthwith comply with such provisions or this permiuhalt be deemed revoked.
Z2 CONSTRUCTION LENDING AGENCY
�-+ I hereby affirm that them is a construction lending agency for the performance of
gL> the work for which this permit Is could(See.3091,Civ.C.)
LI] 1<ndefs Name
D. Lender's Address
VC) 1 eenify that I hats:mad this application and stake that the shots informationt,
F correct.I agree to comply with all city and county ordinances and sum laws misting to
O t.1 building eonsmsauon.and hereby amhosis mpreatnmiss of this city to enter upon the
,rte a1v9womentioned Pmpcny for inspection purposes.
gy (We)agree to son.indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way see=against said City
V z APPLICANTOof the UNDERSTANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARD
Signature of ApplinO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willapplicant or(muni buildingoccupanterreor handle hvudo mamsi
ri
u defined byy tae Cupertino Municipal Code,Chapter 9.12,and IM Han
caIN and Safeq
Code.Section 25532(a>7 All roofs shall be inspected prior to an roofing material being dyes ON. P P Y g g installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it huardnu Oil contamimnts as dcfutmd by the Bay Area Ail Quality Management all new materials for inspection.
Distric"
❑Yes CNo
Ihave mad the de,Sectio mammals 533 add M under Chapter one if et cur SafetyCode,.mount. 25505.25533Ond2553<.l understood do up Wilding
docs not currently which
haw•tenant Nal it a my reponsibifity lc notify the occupant or the
reyuimmcnu which mustbemct Poor 10 ore Cenihcam of Occupancy. ignatOre Of Apphcan[ Dale
Owner or authorized agcor Date All roof coverings to be Class"B" or better