05110025 CITY OF CUPERTINO '�
BUILDING DIVISION PERMIT C0NTRACT(1R IATIO$MATION
BUILDING ADDRESS: THE WINDOW BROKER PERMITNO.05110025
19505 GREENW
OWNER'S NAME: PERMn ISSUE DATE
SAM SETO 2385 LINCOLN AVE 11 /07/2005
NE:
SANITARY N0, CONTROL NO.
(800) 639-4527
ARCHfIECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
coo LICENSED CONTRACTOR'S DECLARATION
fteJob Description
C 1 hereby affirm Nam li
at 1 censed under provisions of Chapter 9(commencing
z vied section 7i)(0)o(Divishm 3 of NC Business and Imfemona Code,and my Ike=is
inraIlrarecandcffai REPLACE WINDOWS & SLID. DOOR
Liana Cl.aa 7Lie.. 9 2
°f� °ate IIcrsDears— n ` (5 WINDOWS W/RETROFIT/3 WINDOWS W/CUT DOWN WALL
ARCHITEf¢ I understand my plans shall W used u public records
7yU
say
Licensed Professional
7 3 OWNER-BUILDER DECLARATION
2 i I I k¢hy airm Nat 1 1. exempt from Na C limitations
Lead.: nyc Law for the
O O following mama.(Section 7U]LS,Business and PnOfeealans Calc:Any city or county
3$ which require a permit t.construct,alter,improv:,demolLsh.or repair any svucmm
_I< prior m its issuance,also acquires the applicant for such permit to Glu signed sulcmcm
thatkmHams:ad pmamrt 1.the pto.isat�of the committers License uw(Chirac,9 Sq.Ft, Floor Area �j�® Valuati`$il 990
rN0 (Commencing with Section7")ofDivision3oftheBusinmandProfusionsCrde)or �I loci
y
Out k is exempt skmGom and the basis far the alleged exemption.Any violation of
Section 70313 by cry applicant for s permit subjects the applic.,to a civil penalty of 3 6 pp 914 0 2 Number
0 0 OF�S Occupancy Type
not more Nan Rn hundred dollars($500).
in -
❑I.uawnv of cite pr.pary,or my rmploycu wiU wagau Nets mlc<ampcnsatian,
will do the work,and me structure is nmin¢nded ar offered for saes(Sita.7014,Basinw I
and Professions Cade:The Comvcrore License Law dote not apply W an owner or Required Ipsp�,*(ons
property who builds a improv Corton,and whodoessuchwvk himselfarthroigh his 4Nf{ ✓
own employees.provided that such impravemenu art not intended or oRucd for We.If,
however.the som the
b r improvementproving
is and did Ona you of compleimprov forn.the owner, B r�
buildv will love cite burden of proving Nat k did Out build or improve for purpose of
ale.).
C 1,m owner of the Propcnt,am cxdusively coarsening with licensed contractors to
construct the project(Sec.70x4.Business and Professions Cade:)The Conuacrort Li
case law Ones not apply in an owner of pmpny'who bands or Improves Haman,and
who contracts for such projects with a contracmKs)Bcerved pursuant in dm Convacm2s
Licvra law.
C lamexemptmear See .Bk PCfor Nisrtuon
Date
11C11y--1a"
WORKER'S COMPENSATION DEC"RATION
1 hereby afro under penalty of perjury ane of Ne following declarations:am and will maintain a Cvuricam of Consent to self-insure for Workers Compm,as provided for by Section 3700 of the Labor Code,for Ne performance of Nc
far which Nis pcmit is Laucd.
have and will maintain Workers Compensation Insurance,as required by st von
ofthe labor Code,for the performance of Ne work for which Nis permit is issued.
orkers Compecoman lnmrana 'v and policy number arte Site Co w Policy No.: 1516330
CERTIFICATE OF EXEMPTON FROM WORKERS'
COMPENSATION INSURANCE
(Thu seaim need not he completed if she permit is foram hundred dollen(SIM)
or mass)
1 certify that in the performance of the work for which this petit is arced,1 shall not
employ any prsan in any manperm as in become subject te the Warken'Compewtion
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:IL after making Na Certificate of Exemption,you should
become subject an the Worker's Compcuauon provisions of the Labor Code.you mute
.JZ foMwub comply with such provisions or this permit shall he deemed revoked.
z CONSRNCION LENDING AGENCY
[-+ I hereby aRmm that thcrt u a comtrvvnn mnding agcmy far the prformancc of
Na wad,for which this permit is issued(See 3097,Civ.C.)
a 'q Landers Name
.7 Z Laft,'.Address
J O 1 canonry that 1 have rad this application and sum Nat Nc above information is
(•' coma 1 agree to comply with all city and county ordinances and sum laws relaung in
0 building construction,and hereby aothorix representatives;or this city w anter upon the
w akve-mcndaned prof ny In,INptdon Puri
F-gy (We)agree to...Indemnify and kap harmless NC City of Coplanar.agLNt
fA liabilims,judgments.costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of Nu prmit,
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURcGU TIONS.p
W - puede-�ILr 11-03-05 Re-roofs
Signatureof ApplicuNCoru emr Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will tk applicant or future building occupant storm or handle hvalloas material
as defined by the Cupertino Municipal Code.Cbapmn 9.12,and the HeaIN and Safety
da.Suction 25532(x)? ( � All roofs shall be inspected prior to any roofing material being installed.
C Yu 64.
Wilt the applies ,Or future building Occupant six equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hwUmus air conuminot as defined by f Bay Area Air Quality Management all new materials for inspection.
District? a /
CYes mfr
I have mad Ne havndoses materials requirements under Chapter 6.95 of Ne Califon
iia Healed k Safcty Code,Sections 25505.25533 and 25534.1 understand thmif the Wilding
does not cumnuy hove a tenant.Nat it u my rupvuffidity w notify Nit matipan,of Nit
mquirt h74-
K astkmet o,toonumaonCcmfiesteoraapaay. Signature of Applicant Date
.w e�2 sem` 1 � oS All roof coverings to be Class"B"or better
Owner or aumomed agent Dam