06060175CITY OF CUPERTINO�
BUILDING DIVISION PERMIT
GU„NLRACTQRTI`iORMATIpN
BUILDING ADDRESS: A1Q(J `�
X
MI HA
PERMrf'0.060601%5
959 GREENLEAF DR
LR'S NAME:
PERMIT ISSUE DATE
MINA RAA
08/21/2006
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLOO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
used under provisioof ChaPW 9 (romcmmg
1 hereby arm that 1 an Ilarm m
'
with Section 7000) of Division 3.f ta Business arm Profession Cede,and my license Is
I. full foreemldefrem.
DEMO SFDWL
License Ons Lt.. Is
Dam Outnumber-
/
ARCHITECTS DECLARATION
C
I understand my plans alWl W used u public ram's
/
s
Licensed Professional
DECLARATION
Oat
Con Clo
I am exempt from the CanuanCo A nm Law for my
I herchy .(firm I am exempt from
Profession Cade: Any
following mama. (Salon 7 cont. Business and city or county
on
V
$20000
which requires; a permit re cores due alert hnpmssu h permit of repair any structure
priorw its issuance, also requires the the for such permit w .c a signed auwmenl
Ft. Floor Area
n
Valuation
inion of
that In is licensed pursuant In the provision of the Contncwr'e License law (CTapter9
l rs
Sq.
(commencing with Somion 700(p) of Division 7 of the Instrument Profession Code) or
that he is exempt thea(rom and the basis for the alleged exemption. Any violation of
AyN NiArtimir U
Occupancy Type
Sauon 7071.5 by any applicants for a permit mbjeca the applicant m a Civil penalty of
rear more Dun RK hundred dollars (SSW).
❑ 1. as, owav of the property, or my employer with wages u theh m[a compensation,
Required Inspections
p
will do the work,md the s4udun ianet intended oraffcred for We(Sec. 7Oµ Businea
and Professions Cade: The Contractoes Liame Law doe rot apply m an owner of
9
progeny who bis ills a improves dxmon, and who des each work himself car thmugh his
own employer, provided that such improwmenu art mt intended"Offered (.rule If.
however, the building or improvement is mid within Oa year of completion. the owne.
builder will have tie buNcn of paving Nat he did net build "improve for purpose of
talc.).
I, a owner of the property am excluiwly contracting with licensed conaectan m
C.C, the project (See 7014, Business sed Profession Cede:) The CoMmetur's Ll -
ave Law dao not apply to an owner Of property who buims or Improv t tierea, cod,
who contracts, far such projects with almnrachms) licensed Furnace, on the Can'ter's
Law.
exempt underSeeBis PCI"thisDau
2AWORKERS
COMPENSATION DECLARATION
1 hereby arms under porosity of perjury eve ofde following dalunio er
ave and will maintain a Cenifine ofCareen m self4usum f"Workers Compere-
IMy
, u provided far by Section 7700 of de Lab” Code, far the performance a( thefor
which this permit is Issued.
awand will maintain Workers Compensation buunna, u required by Sudan
of to Labor Code. for the performance of the work f"which this permit u Issued.orker's
Compensation Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-
Mis cesia sued notbeccmplexd If Ile Permit is f"ma hundred dollen (1110n)
or less)
I anify that In the performance of the work for which this Permit is Issued. I shall not
employanypcnoninanYmannermu cep os j t mthe Warker'Cemp adon
laws of California Dan P
Applicant
NOTICE TO APPLICANT. If. aftr making Nis Ce sifam of Exemption, you Mould
become subject m the Worker's Compensation provisions of the Labor Code, you most
forthwith comply with such provision or this Permit shall W deemed rewind.
CONSTRUCTION LENDING AGENCY
1 herby affirm "Ua do.dirt is s rormrsutinn sending agenry for the perfurmasue of
Me wars for which this permit is kssad (Sen. 7097, Civ. CJ
Lender's Name
1
Lendeh Address
j 1 anify the, I Mw read this application and sum thus Me abaw information is
' correct. I agree to amply with all city and county ordinances; and also, laws minting to
building construction. and hereby autiona mprtsenutivv of this City to enWt Urnn the
above-mentioned property for inspection purposes.
(We) agree to saw, indemnify and keep harmless Me City of Cupertino against
Ilabilitiv, judgments, Costs and expenses which may In my way accrue against said City
in conacgsunec of tho Smelling of this permit.
i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON INT
���_� „J
Issued by: Date l/6
SOURCE REGULATIONS. / / PG
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Hay—�Q/ /
/'iVC.n-m
Re -roofs
Type Of Roof
Si uurc efAppli HAZARDOUS MATERIALS DISCLOSURE �Efite
Will Met applicant car future building "cupmtssaa"handle heandov mamdal
Rind by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety
. Section 15571(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yca WN.
If a roof is installed without first obtaining an inspection, I agree to remove
Will she applicmt or futam building eccupant um equipment or devices which
emit h"aNnv air conumironu u deRsud by then Bay Arta Alr Quality Management
all new materials for inspection.
District?
❑Yv XNu
I have read the h"aMsw. manrials rtyvimmcnu under Chmnr0.95 ofthe Califor-
ma Health & Safety Cade. Sodom 21505.15577 and 25574.1 understand thatifde Wilding
Jan not curendy haw a enant this it is my hamomobility m notify the 0aupan, of de
requiameme which may be metEiior te wen a Carufcate of Cccti
Signature of Applicant Date
06
All roof coverings to be Class "B" or better
Owner or outhorind agent Dam