05050025 CITY OF CUPERTINO n * 5��xaw c= •� ' '''"N^' '�'
BUILDING DIVISION PERMIT ` CONTRAGTR INFQ�tMATIO.�N""
BUILDING ADDRESS: PERMIT NQ,US o s o 02 5
OWNER'S NAME: I PERMIT ISSUE DATE
FRAN N
NE: SANITARY NO. CONTROL NO.
ARCHITEGTIENGINEER: BUILDING PERMIT INFO
BLDG O PLUMB MECH[�
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I ame licensed under proviuow of Cheme
pum 9(comncing
NNSection]IXIU)af Divitlon Sof Ne BudmasW Prof rots Cafe,artl mylkersse is
r� in
full foceAnd
e 'L REMODEL (NO STRUCTURE)
Licenmclau LContractor le.g Np KIT. /2 BATHRMS/WINDOWS/HEATER/SEWER
3
ARCHITECTS DECLAR TION
IundertsnJ my phns mail hemail upublic records CONTRACTOR: DIAMOND HOMES
is Z G Licensed Pmfauionel -
OWNER-BUILDER DECLARATION'
1.00 I hereby affirm that 1 attempt from Ne Cractara Litman Law for the
i. O following amount.(Section]UI 1.mI.S,Business and Prer ns Cafe:My city or county,
S$fi which reyuiw a Permit in...net.alotr,initiative,initiative,pve,e,dcmolhh,or repair any atroetum
prior u,its iu mnetr ii 1 u require the applinm fanuch permit a plc a aigncd suNmcan
that he is licensed pursuanto the provisions of the Contractor's Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division S of the Business and Professions Code)or
$
that he a humid therefrom and Me basis for the alleged assumption.My violation of 128�0 0
Sanction 7031.5 by arty applicant for a permit subjects the Applicant to a civil penalty of APN Number Occupancy 'T�to
ret more Nr
an It hundred dollars
(5300).
C]I,uownerefUmpmpenymmyamployeuwiNwa utheirmlecompenudon,
wilido thewotk.and theavuaurt 6 not intended moQord fertile(Sec.7044,Busimu wired Inspections
and PmfnMona Code The Contractor's License Law does not apply to an owmer of
propeny who builds m improv themon.and who does such work himself or through his
own employesart not provided Net such Improvements anot Intended mofiered forsele.1f,
bowsaw.Ne building Orden of pmem Is mid ingthathedid aonyear of mproefearn.the Owner.of
buildu will have dm burdan of proving that he did not ddld a improve fm purpose of A�
sale. n ^t /
❑L as owner of the property,,B exclusively and cofessi ns with:)The
eCcnnumton i.
contract the pmjea apply
toad,Business and property
who ons Code:)The v enbaslari and
Genu law des nm apply e ts owner or property who builds or imnto M Canton,and,
whomnuaets for such prokets who a eonuauor(q licensed purwm m dre Contractor's
License law.
m aem
❑lapt under Sec. // ,B&PCfar Nle
Owner �rsd--��''WORKERS COMPENSA S
NDECUR—ATION `Dam� lt`\
I hereby of iron under Fealty of perjury ane of the fallowing declar0i m: \J
❑1 ban and will maintain aCmtinwm of Covent to self-Insur fm Worker's Compere
station.as,provided for by Section 7700 of the Labor Cade,fer tits performance of the
work for which this permit is issued.
❑1 hervo and will maintain Wurkeb Compematlon Insurance,u required by Section
7700 of the Labor code,far Ne performance of the work for which this permit is issued.
My Wmkees Compensation Insurance prier and Polity number art:
Cartier. Policy Na: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA71ON INSURANCE
('This rection wed ant becomplemd if the permit U faone hundred Millar(5100)
m hese)
1 mnify that in the performance of the work for which this permit is issued,I shall net
employ any person in any manner snumbw�tt ambrccl.ta the Warken'Compensanon
Laws of California.Data -
Applicant Kjl a.j L v o r r.r0-
NOTICE TO APPLICANT:If.after making this Ccnifimic of Exemption,you should
become subject m the Worker's Cumpcnmtion provisions of thc labor Cost,you must
,J O forthwith comply with such provisions Or this permit shall be deemed revoked.
? CONSTRUCTION LENDING AGENCY
EI hereby alarm that the.4a construction lending agency in,the performance of
t the work for which this permit Is Issued(Sec.3097,Civ.C.)
W�Q Lender's Name
Z Iander's Add.
V Q I ceniry that I have rad this application and sale that Me above Information is
na F conecL I agree to comply with all city and county ordinances and shot laws relating to
Qt..l building construction,and hereby autbodr mpcousnetiw of this city to emm upon Ne
U abuvamendawd property for Inspection purposes.
py (We)agree to save.indemnify and loop harmless,the City of Cupertino against
y liabilidea,judgments,come andexpeow which may in any wayamwalains,said City
V 7 in canm9wnce of the Scanning of this penniL
r� APPLICANT IJNDERSTAN14S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER LATIONS —
Re-roofs
mo ApPli. n - Data
HAZARDOU IALS DISCLOSURE Type of Roof '
Will the applicant or future building occupant pore or handle haucdous malerial
as defined by he Cupertino Municipal Code,Chapter 9.13.and tit Health and Safety
Cosa,Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
[2 Yes
'12115—
Will the applicant or future building occupant use equipment Or device which If a roof is installed without first obtaining an inspection,I agree to remove
it hundnu air conhmironh as defined by the Bay Area Air Quality Management all new materials for Inspection.
iurict7
❑Yes F1Cu
I have mad the hvardnusmaottlatsrequimments underChepmr6.95of the Califor.
nit HGIN&Saay Code,Sced.23305.25533 end 75534.1 un@nwM Nul(Nc building
does not currently hew a mnam,Net it h my responsibility to mrdfy Ne=pan,of Ne
mqulrements which mut met pdM an at ance ora ccruncaanroccupncy. Signature of Applicant Date
5 — All roof coverings to be Class"B"or better
Ow ata hilborurad a n Dom