06040011 I
CITY OF CUPERTINO syn
BUILDING DIVISION PERMIT' V ,Rf�.C, 0lvY1A ,Ip�1\
BUILDING ADDRESS: PERMIT NO.0 6 0 4 0 011
1143 HOLLYHEAD LA
R'S NAME: PERMIT ISSUE DATE
RAGHAUAN EMBAR 04 /07/2006
PHONE: SANITARY NO. CONTROL NO.
ARCH=/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ioo LICENSED CONTRACTOR'S DECLARATION Job DeSCiIpIlOn
1 hereby affirm Nes I em licensed under provisions of Chapter 9(commencing
with Section 7")of Dhdaum 3 of the Business and Profession,Cade,and my license at
+Doi inmOrmmadeffa REVISION- ORIGINAL PERMIT # 05120021
>y�z Larose Claes Lic.6
Dam FIELD CHANGE FOR NEW CEILING BEAM & STL. PLATE
t• TSDSCL
ARCHITECTSDECORATION
f I undermnJ my plans shall he rec
used u Public ords
Ru
It Licensed Profeasimmi
`y OWNER-BUILDER DECLARATION
1 hereby alBm that 1 am exempt from Ne Conuutofa Ucenm Law for the
A o fallowing mason.(Section 703 1.5,Business and Professions Code:Any city or county
5$ which requires a Permit to conNed a@s.Improw,demolW,or repair any structure
prior un its usuenm,also requires the applicant forsuch permit on file a signed sommutnt
ppx< thatheislicensedpursuanttotheprsisionsoftheCourscmr'aUecaceUS. Chaprer9 Sq.Ft.Floor Area Valuation 0
Y P'O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y $ this he is exempt sherefmm and the basis for the alleged eaemptim.My violation of
notaaN ase nmapplicai�(sapermit sabjecm the apPlmam m a ei.;l penahy of ApN Number Occupancy Type
36226019 . 00
❑1.u owner crass pesperty,ser my septaycq with wages as Nen mm cmnpeuWan,
will do the work.and tosuumme Is Out inmnded or OBemd OrSale(See 7W.Business Required Inspections
and Prorealmu code:The Contractors Lianas,Law does Inst apply te in Owner or 9 p /7
property who bulldsor(mprom Neaeon.and whodoesauchwark himse forthrough his
Own employee,provided Nat Such improwmerut art rot intended"Offered ran axle U.
hownm,the building orimpmwmmt is aid within oro year of eempiction.the comer- V
builder will bow tiro buden of proving that he did rat Wild or imPmw for purpose of
L u awrar of the Property,,B gness and conuseUns CAN Iicemed momus'3 i. \`\
natact the project U (Property. Business and Profmmans Cade:)The l carni nso of V
cense Law does not apply to an owner of property who WIW or impram thearan.and,
who contracts;for such projeeu with a mauanor(U licensed peramorm to the Conuacme.
Lice=Paw.
❑I oro exempt under See .Bk PCfmthis n
rls D. "" o 6
—'1N ORKER9 COMPENSATION DECLARATION
1 hemby affirm under penally of perjuryas of Ne foibwing dmlaraOUse
❑IhamaMw imainminaCu Bmmof Coventwulf-innmfar WorI e,Compen-
atlon,as provldcd for by Section 3700.17 the Labor Code,far the performance Of the
work far which Ibis permit is issued
0 1 haw and will maintain Workr(s Compensation Insurance,u mluired by Section
3700 of the Labor Code,for Ne performance atone work far which thus permit is lasued. '
My Wartels Compeuadon Wurantt artier and Policy number ane:
Comm. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
I
(This section used set he completed Hdte permit isfmanc hundred dollars($100)
or less.)
1 mNfy that in Ne performance or the work for which this Permit Is Wood.l NUI em
employ any raninooy an r�alBmt�O�orkdrs CranPenvuon
Laws of Celt aMt Date I:J�ei 6
Applicant ' i'
NOTICE TO An the Wort:If,agar pensng Nu Certificate th Exemption,boCyou ushould
an=
become subject to the WaheYo Compensation this pavipoai of the Tabor Code you rosea
.J O forthwith comply with such pmvbinas or Nus Permit shall he decreed revoked. -
Z'r CONSTRUCTION LENDING AGENCY
p: I hereby alarm that there AS a construction lending agency for the performance of
U3
U3 the work N
for which is permit us issued(Sec.3097,Civ,C.)
O
Uadoes Name
z
Lender's Addres, .
t.7 Q 1 Us iry that I bow read this applimden and sum Nu the Amn information is
IL.F tonna I agree to comply with LI city and county on ina ess ad Sum laws relating to
Q V Wilding construction,and hereby audimire«PMSmLAKna of this City to enter upon Ne
{37
Sit ovmmcnduncd property for inspectian purpeus.
0. (We)agree to ase,indemnify ad keep hamlrss Ws City of Cupertino aimust
y IiahilAJq,Jodgmenb.caw and qPa.which may in ay way attar agalut Said City
(,7 in COMMS seam of the pa0ng Of this pemlt.
r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by, Date
50 CE REGULATI NS.
Re-roofs ,
Signuu ,of Applian✓Conuactor D�
HAURDOUS MATERIALS DISCLOSURE Type of Roof
WAR the applimm or future buliding aecupmmm whandlc hawdow material
Orad by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
.Section 35532(4)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes XNo
Will the applicant or future building Occupant on equipment Or dealcas which If a roof is installed without first obtaining an inspection,I agree to remove
emit huaMnm air coouminars u dcfiOcd by Ran Bay Arca Air Quality Management all new materials for inspection. -
District?
CYm No
1 haw mad W h=Lldmn dtlsmquimmem .&,Chapmr6.95oftheCalifon.
nut Hca h&Safety COM,Sectiou25505,25533 and 75534.1 understood Nmirue building
does net cummly ben•trnnn,Wt it u my reap ntsibilily M ratify the Occupant Of the
mquimmcnu whleh W met prior m Avuwac Of a certificate arsculatfurp Signature of Applicant Date
blA
wear or auNorisd spent 04 b Dote All roof coverings to be Class "B"or better