04090059C ffY0FCUPERTtN0_..
eulLmNc,urvlslovPERMIT
i"EINCIADDRESS:
PERMIT N`b4 090 65 9
2FC
O902 HANFORn nR
0" EWS NAME:
PERMrr ISSUE DATE
HARISH A:GASTYA
NE:
SANrrA4 11 lz.^'-CONTROL NO.
ARCHn?ZrMNGIKEER:
BUILDING PERMIT INFO
ELECT PLUMS MECH
21BLDG
LICENSED CONTRACTOV DECLARATION
by affluent mm I not licensed undonowfillocas of Cluspur, 9 (Commencing
Job Description
with SW'd"0*qOQ[) of Division 3 offt Buri and! ftlossumer, Code. and my ficimat U
I In
Me e (" 'Cz- I se? 2
SFDWL-2 STORY 4,271 LIVING
Lkenm
oatsaminallor 14u ita,'- -rF- h.L—
GARAGE-709.SQ=.
RAW
AR . ITECTS DECLARA71ION
luncomiturrianyppisqualliveduard"P- �Cmm
9 A
JAN le
OWNER-BUILDER DECLARATION
ykirby am C that I am eacmpt from the Condamine, License Law for the
?fir,^,
following mosm. (Section 7031.5, Business and Professions Code: Any City or courdy
which requires a Permit to comeduct, shm, improve, demolish• or repair my structure
prior In its issuance. also requires the applicant for Inch pomit Ou file a signed aluminum
thm W is licensed pummaram the Provisions of the Contractur's License Law (Chapter 9
Sq. Ft., Floor Area"�Uu
UILLV"ju,
(Commencing with Section 7030) a Divisomi3 of ft Business and Professions Code) or
that he is exempt therefican, and the basis for the alleged carcurnimme. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for. Permit subjects the applicant in a civil penalty of.
Out mom them are hundred dollm, (ML
32630057.00
[i Lassiname'adicisomenyormy susp,
will&ftwokoW=aumbnmi.Wnd .offemdf.ule(See.70 .Bu ness
Required Inspections -
and ftfecadom Cc*: The chmmcdrA I men Law dm MI apply in am Owner of
propery.but buildsorimproves, thencern,and whodoessuch work hunamtforticarough his
Ownmplorn,provddedthatuchimprovemcommmilnmndedaroffemdfor&,ic.1f.
hcrwscLcr, the Wildinjorimprovementismild within oneyearofccurplation, theowner.
builder will have the burden of proving chat he did nm build or Improve for purpose of
sale.)..
[3 Las manver, of the property, am a cluldivelycowmactifts with ficaustand Conuumn in
craulnuct the puttect (Sec. 7044. Business and Profession Code:) The Combscures U.
ocrum Law does not apply in in owner of property who Wilds or Improm Kenton, and
whocontracts, for such projecta, with scormuclor(s) licamsecipursuma in the Contruclors
License Law.
❑ 1 sto eaturpt under S. B A P C for this
r Date
- WORKER'S COMPENSATION DECLARATION
I hereby afErm under penalty of perjury one of the following declarations:
I havc.od will maintain a CnificatenfCcumem wandr-instme forWmIss"IsCompen.
it
cation, so NoAcmd for by Section 37M of the Utum, Code. I. the puffinemosec Of Over
wor" for which this Permit is mumd,
I
0 have it ill mai min Worker's Compensation Inewmance, as required by Section
3111of the Code, for dre performance of me work for which this Permit is lsaadccd.
My W.,mes Compensation In... cant artier dP [I mite, me
Co 0"
Ca
"R
CERTffIcAOFF1;;E 051117
COMPENSATION INSURANCE
(Thessucthm account bactimpleted Ifilic permit Isformse hundred &It= ($1010)
or lea.)
I onnify that in the performana of the work for which this ficrod, is issued. I small not
employ any person many mancerso It in become subject in theWorkers'Compentardon
Laws ofC.1fifininda. Date
Applicants
NOTICE TO APPLICANT. If. after making this Cenificato of Exemption, you should
become Subject to the WOrkC1`I COmqPCmamOm Pinovill Of the Labor Code. you mum
forthwith comply with such prevision or this permit shall On deemed mokcid.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a Construction lending.1civey for the performance of
the work for which this peri is issued Is". 3097, Civ. C,)
Lender's Name
Lender's Addreaus
I comfy that I have read this application and sum com me above information Is
entrust, I agree to comply with all city and County ordinances and now is" relating in
holding construction, and hereby audintrim, mforessuntalim of this city in cover upon the
above-mentioned property for In,viction purposes.
(Wo) agree in save, Indemnify ad keep harmless the City of Cupertino against
liabilities, jodgincrits, costs and cx,amumai which may In my way acerae against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
URCE REGULATIONS,
Re-roofs C,7
Type of Roof
28
Adim Ofrxipr4pWannTVCm,2.unr Date
HAZARDOUS MATERIALS DISCLOS7UV
Will the applicant or form Wilding mictiparrul sime or handle lossemdous MSM481
Is, defined by ft Cupertinct Municipal Code, Chapter 9.12. and the Health and Safety
ode. Secum. 25532(a)?
All roofs shall be inspected to any roofing material being installed.
0y. V No
prior
If a roof isinstalled without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
it hazardous air contaminants as defined by the Say Aics, Air Quality Management
all new materials for inspection.
$idea?
0y.
I have mad the baurchum materials requirements undurChapuO6.95 of the Califor.
-1-Houlli Sd.iyCd., Sad.. 25505,25533 and 25534, 1 understand! thatifthe Wilding
but currently have a unrand, 64, it 6 my responsibility an nodry the occupant or Jim,
I
atuFe of Applicant to
requirements which in= be met phorudisdur.a. certificate oroc"p7z.
L
7,th �vzdgcnl
All roof coverings to be Class "B" or better
Owner �X`z
or D�.-