04040075 CPERMITY OF CUPERTINO
BUILDING DIVISION PERT CONTRACTOR INFURMATIQN
BwZDINGADDRESS: PRICE BROTHERS CONSTRUCTIO ERR)"m"°04040075
11
OWNERS NAME: PERMIT ISSUE DATE
PRICE BROTHERS C N
E; SANITARY NO. CONTROL NO.
ARCHI]EC(ENGINEER: BUILDING PERMIT INFO
BO 0 PLO MEOCH
Lapp LICENSED CONTRACTOR'S DECLARATION JobDescri tion
I 1 bert amrm ntl I am lice sed sande provisionsm Chapmr 9(mmmencin{ p
"Bee
)af DE, 3ofthe Bu . Noticed dle'sndm license Is
in full to deNeeL ADDITION 777 SQ FT/REMODEL
5 o;� U.01 naam CONTRACTOR PRICE BROTHERS CONST.
AR llheusSD A710N
5y 1 undcrsund my Plant atoll he used as public records
LE
c
Licensed Professional
^ OWNER-BUILDER DECLARATION
E 0 0 I hereby.(firm that I em exempt from me ssionsCConnector's :My c Law for the
E00 o whichfollowing reason.(Sccdut 7(131.5, t.after. andom e.demolish.
Cade:My city or county
$fl! Emm E us hrosixec•portio ne ermmrue, slur.Improv,d ssrch permit.ri e a sig ed strucumemm
men heiuceeused puraurequirhe me, of for Conowrrnismiccom gnedsaumem
< thuhelalinmedpucedom7 uprovuiemofduCenuacmhlJaveLaw(CMpur9 Sq. Ft.Floor Area Va�iltgrg000
S
(commencingaisxe pt therefrom
and of basis n3 of the Business exemption.
W Proon.Myaru Cntle)of
�.. that he la exempt 0urtfrom and du bests for me all.{ed eumpdan.MY violation of
Section 7031.5 by any applicant for s permit subjects the applicant as a civil penalty of APN Number . Occupancy e
not...than 0y handrail dollars($300). p y T>'p
01,as owner ofthe property,or my employes,with wags,as men sole compensation, 36221005 . 00
will do thework.and the moan"isnotlnuaWed oroaered for sale(Sec.7014.Business
no Professions Code:The Conuecmfs Lkctue Law dots rot apply m an owner of Required Inspections
prepeny who builds or improves thereon,andwho does such work himself or mrough his
uwnemployces,provided mat such Improvements are notlrneMed moRered forsam.If,
however,the building or Mprovemmt is said within an year o(nmpletion.the owner.
builder will haw 0u burden of proving Wt he dm not build or Improv for purpose of
sale.).
❑1.as owner of the property,am"elusively contracting with licensed consncmn to
construct the project(Sec.701,Business and Professlom Cade:)The Controcur's Li.
came Law docs not apply m an owner of propeny who buflN or improm demon.and,
who contractsfor such projects with a nuacmrtU licensed pursuant snt the Contractor.W L
oma law.
0 1 am exempt undo Sr.. .B @ P C for rola reason
Owner Dau CY�
WORKER'S COMPENSATION DECLARATION /
I hereby spline under pemlty of perjury one of 0u following decleretmns: O
ave and will maintain a CenlOciu.(Consent In self-mann for Worker's Campers-
orlon,as Provided for by Section 370 of du Labor Code,for me performance of me
work for which this permit is issued.
1 have and will maintain Worker's Compemadon Insurance,as acquired by Section
3700 of the Labor Code.for the per(ormuueo(Uu work forwhlch mis permit is issued.
My W/q��� sCampewda msunna casriar ehd\2a1lmNsumbcr art:
CMier. ` Paltry Na.: S Z I !R re l b`l4
CERTIM ATE OFFXFFMMON FROM WORKERS'
COMPENSATION INSURANCE
(Odssectlon need not the completed if the permit Is froom hundreddDllers(1100)
nr less.)
1 unify the,in the p uroda nn of the work for which this permit is issued,l"I not
employ anyperson in any manner an as an become subject to me Woriurs'Compenu0on
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificau of Exemption,you should
become subject to the Worker's Compensation provisions of the lather Code,you most
.,O forthwith comply with such provisions or this Permit shalt be deemed invoked.
r y CONSTRUCTION LENDING AGENCY
,4 I hereby.fibro that there It a mmWCWn lending agenry for the perfurmence of
C> the wish for which this permit is issued(Sec.3M,Civ.C.)
Lender Name
.7 z UntleYI Address /—
V 1 certify that I hay reed mit city
and ours and sou mu the above information sng o
iy builds 1 agar m comply With all city end county msti ordinances and sou lent r Wing m
Q LrJ building comWaion,and Money eumorirzrposes utlres of this city mentor upon me
W ahDVC-menllO.Cd, save errmunitInspecyIDn keep
(Wel ag e m say,ad expenses
and kap harmless the City of Cupertino s idainty
new Z Ifiin consequence
o sequen eoforccoNandof thiss,mitch may In any wry ensu.against said City
().Z. t.
APo%p{,I�,��1W UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da
SOUWE GULAnO S.
I'VL ts J � l-oi Re-roofs
Signal=ol'AppliemUCo tcum Date
HAZA DOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store"handle harudom material
as dented by the Cupenino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes vi'J No
Will the applicant or future building accupam use equipment a devices,which If a roof is installed without first obtaining an inspection,I agree to remove
hmardnus air cmumiasnu fired by the Bay Ams Air Quality Management all new materials for inspection.
mimT
❑Yes Nu
I h.v read the hmardam materials requirements under Chapter 6.95 of the Califor.
.is Health&Safety Code.Secdam 25505.25533 end 2553,1 undersand met If ft building
does out currently have a u tan4 then it is my responsibility to nomy me occupmu of the
mqummentsw muube ctpN missumnofaCerdfcamotOccupmq. Signature of Applicant Date
1.6All roof coverings to be Class"B"or better
Ownsumorived agent Dau