04010016 CITY OF CUPERTINO
BUILDING DIVISION .PERMIT X-ONTAXOTORiINFORMATION
f3.n.� Axa r. .fix,-rb ?xzXist3 �. 4.a rn[.v:y
BUILDING ADDRESS: THE WINDOW BROKER PERMRN00401.001.6
'RS NAME: PERMIT ISSUE DATE
JUN
PHONE: SANITARY NO, CONTROL NO,
(800) 639-4527
ARCHITEMENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30Zp LICENSED CONTRACTOR'S DECLARATION O O O
EI hereby firm that I em licensed under provisfoe of chapter 9(commencing Job Description
nib
no Section 70M)or Division 3 or ft Businenarb Profcssiuns Code,endmylicarmia
j�_< tnfull(oreeanOcffen. • •y �y 2 WINDOW REPLACEMENT
License ClyF'_ - Lic.a
Data Comomr
R IT er-S DECUUAAR�� I'
undersand my plana shall be used as pull mend,
g the� Licensed Professional
OWNER-BUILDER DECLARATION
+� E I hereby afford that Into exempt from the Contractor's License law for the
i O 0 (allowing reason.(Second 7031.5,Business and Profcuinm Code:Any city or county
$ which mquires a Permit to cMmM,.a@C improve,demolish,rc repair my structure
Zi prior to its issuance,also roquirestbe applicant for such permit to File A signed statement
C
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
$ (Commencing with Section 7fy10)of Division 3 of the Business and Profusions Code)or
that he u exempt durtfrom And the btu for the allcScd...,do,Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3( ' I912�)IISerO 0 Occupancy
not more than five hundred della.($300). P y Type
Q I,u owner of Ne property,or my employees with wages u their mlc compensation,
will do Ne work,and the structure is net intended or offered forsale(Sec.704,1,Business
and Professions Code:The Conmcmh License Law docs rat apply to an owner of Required Inspections
prepeny who huildsor improve thereon,and who doessuch work himmlf or through his
Own employ.,provided thatsuch improvements m not Intended oro@red rental.If.
however,the building or improvement is mid within one year o(mmpletion.he owruio- R;-
ID,
builder will hale the When of proving that he did nm Wild or improve for purpose afatale � �' �❑I.u owner of the property,.m uelus and wnfncting with licenud undodus'. accnm LA the es not pply(Secto a n,Bninw and rmwhoWiods Code:)The Canlrm on. Iwho Lawdocsnotapplyjean ownero(propeny vice sedpofimproves Centro,who mnmcu for each projects with a eamm�or(s)licensed pu.uem oo the ConuactoLkeue law.❑tun exempt underSm. .B&PC far thisrt �Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty o(perjury oro e(the followinL dalaruiou:
❑1 have and will maintain a Ccrdfcate of Consent to self-Insure for Werker'sCompen-
tation.as provided for by Section 3700 of the Labor Code.for the performance of dre
work for which this permit is issued.
❑1 have and will maintain Worker',Compemation Insurance.as required by Section
3700 of the labor Code,for the performance of Ne work for which Nis permit is Issued.
My Wer/kee Comp/e'wtion luunmx a7rti'er anal aliry nu�m[pe/n
Cepici-N p(�F Iw IIIS DMXs T'r No WORKERS, vv
liar C12
ERTIFI OMPENS EM FROM WORKERS'
COMPENSATIO INSURANCE
(This senlom need not W completed i(tbe permit is for one hundrnddollm(SIM)
or len.)
1..try dust in Ne performancc of the work for which thi,permit is issued.I MALI nut
employ any peon in any mmner m as m become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Cenificau of Exemption.you should
become subject to the Worker's Compensation proviatou of the labor Cede,you must
.JO forthwith comply with such provisions or this permit shall be dcemed revoked.
'ZV) CONSTRUCTION LENDING AGENCY
(-t rN.r I hereby affirm that then iso commotion lending for the performance of
rGthe work for which this permit Is issued(Sec.3097,Co.C.)
QLandes Nme
=Z Landers Add. .
[)Q 1 certify that L have read this Applicmion and suite that the above information is
(, correct,I agree to comply with all city and county onlinances and state laws relating to
Q U Wilding communion,and hereby euthorihs representatives of this city to enter upon Ote
07 ahnvomemioned properst(a iespenses pugnms
gy (We)agree to eve,indemnify and keep harmless the City Of Cupcnino againsl
y liabilities,judgments,granting of this Xwhtch may in any way aeeme Agalnsl tail City
U ,'� AcPLICANT of do UNDERSTANDS
this permit.
APPLICANT UNDERSTANDS ANp WILL COMPLY WITH ALL NON-POINT Issued by: Date
SORCIw '6z `-1— �
Re-roofs
Si u.of APPlicaHAZARDO � Data
HAZARDOUS MATERIALStDISCL
And0crtac Type of Roof
Will the applicam or future building occupant And Ka�die bloodom msufal
as defined by the Cupenlnn Municipal Code.Chapter 9.12,and the Health sed Safety
k.Section 25532(x)?
❑Ye, I".
All roofs shall be inspected prior to any roofing material being installed.
Will the applicantor future building occupanl me equipment or dcvIcut which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha>ardous air comnminanu as dcrncd by ted Bay Area Air Quality Management all new materials for inspection.
Oimrict7 p
❑Yes 'dl Nu
I have mad the hamniouss`matcsialnequircmcnts under Chapter6.95 o(the Califon
ria Health&Safety Code,Smoom 25505.25533 and 25534.1umlc.and thuirthc Wilding
doe not cumn0y have a tenm4 thm it is my reepomihility i..or,t mcupant Of the
rorements tw
yuihick bemct brwissuanccafaCerdfuauofry Signature of Applicant - Date
OnNirg or authorized agent V ° pate All roof coverings to be Class "B"or better