04090047 CITY OF CUPERTINO - '''4:3'E' t..
BUILDING DIVISION PERNUT '^; "011TRAC^ C�ORANFCIRMATI,UN
BUIWING ADDRESS: RONALD S MILLER rmmiTN'04090047
oo
ER'S NAME: PERMIT LEVE DATE
RONALD S MILLER 1 on
ONE: SANITARY OL NO.
ARCHITECT/ENGINEER: - BUILDING PERM IT INFO
BLDG ELECT -PLUMB' MUCH
(� 0
eco LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Nal I am Rebound under Provisions of Chapter 9(commencing Job Description
ith Section 70110)ofDivixion 3 of the Rostrums and Proiessa m Coda.and my Iiceme is
^ in full fame and,(lect.
uanw Cl. Lt.N ADD 914 SQ.FT. (MUSI'C/GUEST RM/BATH)
Dem n
Qoctor
ARCHITECTS DECLARATION ION
phip I undcraund my plums Mall W usual m public named,
3y, Licensed Pro(ummnel
�m OWNER-BUILDER DECLARATION
1 hereby affirm that I em exempt from he Contractor's License Law for the
DO following moon.(Sudan 70315,Business and Professions Cade:My city or county
29 which requires•Permit to conmrtuL slur,improve,deradim,of repair any uructme
Ny prier in its issuance,also requires the applicant for such permit to file a signed suamenl
`c that he is licensed pursuant so the previsions of the Common',License Law(Chapter 9 SCI.Ft.Floor Area - .. Va UatlOn` - "
a $ (commencing with Section 70D0)of Division 3 of Ne Businsm and Profusions Code)or
� .. thin he B mempt Nere(rom and he bum lar the alleged memptim.My violation of ..wv4,myyw.T� •�rraa..��
Sudan 7031.3 by arty applicant far a permit subje a,he apPliarat m a civil penalty of 3 2%NCgslDnmter0 0 Occupancy Type
M mare Nan Bw hundred dolts($300).
I,mawner of tiw property,mny employees with wegmm Neirsulecompenution,
.tilde the work and the structure isnot Mended aroQerad fm laid(Sm.7044,Busirmm Required Inspections
and Professions Cade:Tho Contractors U.Law does ml apply m an owner of 9 P
property who builds mins promo Nersan.and who dose such work himself or through his
own employee,provided IMlmchimprovenanuart noHnuMed oroRerad founde.If.
however,the building or improvement is sold within arc yon afmmpletioR,the owner- -
Wilder w10 have N,burden of proving Net he did not build or Improve for purpme of -— -
mm.).
owner of the property,am exclusively comneWg with licensed contractors in -- -.
construet the Project(Sec.7044.Business and Profrssions Code:)The CmtraceYa U-
.U.does nai apply to ar owns of property who builds or improves hereon.and.
who contracts(ar mpbq�GN wth a mnuanar(q licensed pursuant m du Cmannu '.
License Law. (/ r5/
❑1 exam up'pI ec. .B P C for his moon
Data
T WORKERSCOMPENSATIONDECLARAT30
1 hereby same under penalty of perjury ane of he following declandons:
737'
have and will maintain a Certlikete of Consent to self-ensu a for Waiters Compen-
sation, .
u provided far by Sauna 3700 of he Labor Cade,for de,performance of the
for which his Permit is amount -
haw and will maintain Workers Compensation turn,u required by Section
of lie LaborCode,far he perform nam of Nn work far which Nis permit la issued.
orkers Compensation Ince encu carrier and Policy number sec:
er. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thissectim need not he compleu l BLye permit Is pontoon huedted dollars(SIM)
or ton)
I certify hal in the performance of tier work for which his permit is Cued,I atoll not
employ soy person in any mannerso as b became subject to tie Wodu:n'Compensation
Laws of Calif rola.Data
Applicant
NOTICE TO APPLICANT.IL aMr mekinp 01,Cortificale of Exemption.you should
become subject to the Worker's Computation provisions of he Labor Code,you mum
.JO foMwilh comply with such provisions of this Permit shell m domed mated.
z CONSTRUCTION LENDING AGENCY
[ti Ihereby affirm Nat there iso coostmctina lending agency for Ne performance of
rl? the wart for which Nu permit Is issued(Son.3097,Civ.C.)
Igl Q Lenders None
=z Looders Address
U Q 1 unify that 1 haw read this application and sou men the above infomntim Is
epnceL 1 agree m comply with all city and county oMnances and sum lave reaming m
O building Convection,and hereby authorise mpresenlatives of this City m enter upon the
L� Lg7 shove-mentioned property for inspection purpo¢s.
(We)agree in an,indemnify ad keep humlmar the City of Cupertino against
liabilities.judgments,ensu and ex which mayin any.
ayacome against WdCity / %/
U z incomaquemcalhegrenu the permit.
PPLICANT UNDER NDSANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
PdUR ;C /2^�' Re-roofs
9y�namofA I/Cantmctor au
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant w ec
future building occupant store or handlers am material
de0md by the
Cupenina Municipal Code,Chapter 9.11.and[be HesIN and Safety
Section Iss3z(an
❑Yes All roofs shall be inspected prior to any roofing material being installed.
No
Will the applicant or future building accupent use equipment o devices which If a roof is installe -without first obtaining an inspection,I agree to remove
7DWricl?
heaamous air contaminanu u defined by the Bay Arm Air Quality Management all new mate ' s for inspection.
//❑Yes �Iv'u Ihavc read tier 4s� m5505. 553requ3reen5M.1 un Mpter tiusofdteWili( g /4v7/ Us �/IN85afct ons25303.23377um2331/.lundcnwbNuiftie Wildin J-1 `/[J_ L 1 eurren)I ave ant het it u my mspomihility m notify tin occupant of the' is i mbemet krmtusecofaccrdMateofoccupancy, SI atureofApplicant Date
r mNarisedg2 , Z All roof coverings to be Class "B"or better C
ens Date