04030137 CITY OF CUPER'I'INO , O' 's !'- Ns uF®..:*vR%kM- 'sATI'O`'(
NBUILDING DIVISION PERMIT CNO
:
BUILDING ADDRESS: ROD BAUER PERMIT NO 04030137
C)IR PT PAKrR DR
�ER'S NAME: PERMIT ISUE DATE
ROT)
ONE:
SANITARY 0. N OL NO.
ARCHOEC(ENGINEER: BUILDING PERMIT INFO
BLDG EtECI' PLUMB MECH
+�ioo LICENSED CONTRACTOR'S DECLARATION Job Description
YvF 1 M=by affirm that I em licensed under previsions of Chapter 9(commencing p
6Zym with Seemm 7")of Division Sof On Busincssmd Professiau Code.and my license is
in full force and effect.
C.
License class Lie.« DEMO (E) POOL
ni-a DateConvector
21 ARCHITECTS DECLARATION
�i 1 undcraunJ my plan shall be mud u Public records
Licensed professional
g OWNER-BUILDER DECLARATION
1 hereby.bore the,I an eumpt from Nth
e Com sere,License Law for e
ac following mason.(Section 7031.5,Business and Precisions Code:Any city m County
Q� which metuires a permit to Consumer,alter,improve,demolish,or repair any atrucure
FIy poor in its issrmitc.alsu mquiru Neapplicant for such permiuo file.signed sutemcm
< that he is licensed pursuant to the previsions of Oc Contractor's 1Janac law(Chapter 9 Sq. Ft. Floor Area uat on
�$ (commencing with Section 7")of Division 3 oftW Business and Professions Code)or
Our he is exempt therefrom and the basis for the alleged exemption.Any violation of
not in than
by vry applicant for a perrnit subjects the applianuo a civil penalty Of 3 1P!UZ*er0 0 �qcF upancy Type
not more Nan fisc hundred dollars r.pare.
Fl I.as owner of Ne property,in my employees with wages as their sole compensation,
will do the work and the sesame is nminmaded oroLfcrW to,tam ISa.IMI,Busineu
and Professions Code:The Conomines License Law doss Out apply or an Owner of Required Inspections
property who buildsor improves tiereon,and whodoessuch work himael(or through his
own employccs,provided Nat such improvements am not intended in offered for sale.If.
however,the Wilding at improvement is sold within one Kv of completion,the Owner,
builder will have the Wrdert of proving that he did not Wild or improve for purpose of
sale.).
❑1,u owner of due property.am exclusively contrating with licensed Commitment;to
construct the project(See 7004.Business and Profession Code:)The Contractor's Li
ccue Law docs not apply in an owner of property who Wilds or improv themon,and
who contracts for such projects with a contractor(s)licensed pursuant an the Contractors
L' me law.
an ease e ,,mudcrr1See. B&P C for Nis mason
//S VJL Dahl�
WORKER'S COMPENSATION DECIARA N
1 hereby affirm under penalty of perjury one Of the fallowing derivations:
1 have and will maintain a Cerdham of Consent to self-insure fa Workers Compen-
sation,as provided for by Section 37M of On labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as mqui=d by Section
37W of the labor Code,for the performance of the work forwhich this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section reed not W completed if the permit is furon,hundred dollars($100)
m Mss.)
1 unify Our in the performance of the work for which this permit is issued.I shall not
empig any perrssoorr�s+s�Ea�ny mannerso as m become subject to On Workers'Compensation
Laws of CaI foraiaB4m
Applicant LLll ".4_1
Non E TO A ANT: L after making this Certificate of Execr ion.you should
Ecco bject to the Worker's Compensation provisions of the Labor Code.you most
.JO foM comply with such provisinns or this Permit shall W deemed revoked.
'Z '--' CONSTRUCTION LENDING AGENCY
I bemby affirm Nat them is a Conswction lending agenry lot the performance of
C(�
to work for which this permit is issued(Sat 31NT,Civ.C.)
1 Q Lcndcr's Name
=Z Undeh Address
U O 1 ecnify that I have mad this application and sum that the above information is
P correct-I agree in comply with all city and county ordinances and sum laws relating to
�U Wilding construction,and hereby auNmire mpmscnmircs of this city to cnmr upon the
W .love-mentioned property for inspection purposes.
(We)agroe to an.indemnify and keep harmless the City of Cupertino against
f�q lubilidee,judgments.costs and Can.which may in any way.11.against said City
U in conaequenec or the granting o(this permit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGUL` NIS.
'3� '! 0� Re-roofs
Si ore of pplicanUConoecmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or future building Occupant nom or handle hams dous mum ed
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safe,y
dc.section zss32(a)? .6sO All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the aphasia or tutu=building Occupant esu equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haundous air contaminants as defined by she Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes .�tlu
I have mad the hmandous materials requirements under Chapter 6.95 of the Califor.
nix Nesbit Safety Code,Sections 25505.25533 and 25534.1 mokersaM dura if the Wilding
docs not currently have a tenant.that it u my m tionsibility m notify the occupant of dm
mqui=men which mu be met poor u issuance of a Certificate of Occupancy' Signature of Applicant Date
ner a amhoovea.gent 'D,m All roof coverings to be Class"B"or better